PIONEERS IN THE
FIELD OF EPIDEMIOLOGY
DANIEL DRAKE’S SYSTEMATIC TREATISE
PIONEERS IN THE FIELD OF
EPIDEMIOLOGY – 19TH CENTURY
Man has always related the ills he suffered with the land he tilled; medical geography is more ancient than Hippocrates Work, Air, Water and Places, yet centuries dragged by before we troubled to record the details necessary to determine cause and effect. One reason for this seeming lack of interest was that for many centuries, disease was considered punishment meted out on man by the gods; through the early Christian era until the time of the Renaissance, sin, with disease and disaster were cause and effect. The scientific discoveries and the geographic discoveries especially of this continent, as well as the religious dissensions of the 15th and 16th centuries turned the attention of scientists again on the relationship between disease and geography. Early explorers and settlers when describing new areas, described along with the ecological conditions of the land, the physical attributes of the inhabitants and the illnesses that the explorers endured. During the 17th and the 18th centuries hundreds of articles and books were written on the incidence of specific diseases or of diseases of a specific area.
The middle decades of the 19th century however, can be called the golden age of medical geography or of the study of the geographic pathology. Two publications appeared in this era that attempted to synthesize the then existing knowledge; the publications were: Daniel Drake’s A Systematic Treatise, Etiological, Historical and Practical, on the Principal Diseases of the Interior Valley of North America, as they appear in the Caucasian, African, Indian, and Esquimaux Varieties of Its Population in 1850 and August Hirsch’s Handbuch der Historich- Geographischen Pathologie in 1860. They were hailed from birth as the major contributions on specific medical geography or medical topography. Accepted, referred to, quoted, neither work has been subjected to modern analytical scrutiny, and despite their common subject and origin in time, never have they been compared.
It is not the aim of this paper to review the history of works on medical geography, excellent surveys by Light in 1944, Barkins in 1946, Grmek in 1963 do this. The intent of this work is to place in juxtaposition two men doing original work on a common topic, from a common scientific background but dissimilar cultures, to see first their aims, their methods of work, the organization of their final product and the influence they had in the succeeding century.
Original work, its form, method of preparation, and motivation is said to be determined by the culture from which a man writes. One’s perception of his world, his reaction to it say Barbu in Problems of Historical Psychology is not only a reflection of his biophysiological makeup, but also a reflection of “The specific organization of his mind within a given socio-cultural setting.”(1) Drake was a product of the Americans Midwest’s great adolescent growth; “Nothing in all history had ever succeeded like America and every American knew it,” Commenger says. (2) Drake repeats this, his society is one in which “A man found freedom, facility of changes, ways to wealth are laid open.” (3) Praising this land with a “Mystical, patriotic ecstasy,” (4) was clearly his motive from the Notices of Cincinnati in 1810 to the Treatise in 1850. Drake’s prose, his subject and his motivation have their roots in his love for the Valley.
In a recent reprinting of a compilation of Drake’s works, historians Shapiro and Miller of Cincinnati write: “Drake is remembered by historians for what he did not what he was” (XI) “Indeed for Drake the pursuit of science was always a practical activity, for what was true was necessarily functional. Science was thus the handmaiden of humanity, providing that knowledge which was essential not only for man’s happiness or prosperity but for his freedom, and hence for the attainment of his proper estate.” (XXII)
“...Yet to the end he remained true to the Baconian methods which had served him so well in the past. He based his conclusions on observation, and resisted with all his will the generation of explanatory hypotheses which would have to be accepted a priori.” (330)
Drake always suited the style of his prose to his subject; in the Systematic Treatise the notoriously tedious details of latitude, hydrology, and topography are presented in a finely balanced form that is lucid and clear, but never dull. His opening paragraph of Book 1, part one is characteristic: “The Interior Valley of North America begins within the tropics and terminates within the polar circle; traversing the Continent from south to north, and passing through the entire northern, temperate zone. In the south it rests upon, and is deeply indented by, the Gulf of Mexico; in the north it bears a similar relation to the Polar Sea and Hudson Bay; the latter penetrating it so deeply, as to come within twenty-two degrees of latitude of the Gulf of Mexico. On the east its limits are the Appalachian Mountains, which extend from the thirty-third to the fifty-third degree of latitude, each end terminating in a low water shed. On the west, the immense chains of rocky and Sea-side Mountains, beginning within the Torrid Zone and ending beyond the polar circle, secluded from the Pacific Ocean. These mountain borders, as may be seen on the map (Pl.1), diverge from each other as they cross the continent, and thus the Valley regularly widens as it passes from south to north.” (p.5) (5)
On the areas he knew and loved intimately, he becomes rhapsodic; with his “pen of an angel” (6) his enthusiasm is transported across the boundary of paper; through the beautiful region of the palisades he knew so well “the Kentucky River winds its way and by its very repose seems to say only its work of excavation is finished.” (7)
It is hardly surprising that in his method of gathering information Drake actually “ascended our streams to their mountain sources or descended them to the sea, at points exceedingly distant from each other.” (p.2) (8) He traveled 30,000 miles when he was over fifty. Travel that was such a joyful labor that he apologizes in the Preface for the “much abridged...time spent on bibliothecal research.” (9) -----Long journeys of observation, repeated through a large part of several years, with elementary teaching in winter have much abridged the time for bibliothecal research; and perhaps, even diminished the taste for that mode of inquiry. (V) Drake’s goals for his work were one to provide a “useful manual for daily reference,” on diseases for the physicians of the Valley, and two, by the Treatise to furnish “future and more gifted historians with a picture of the etiological conditions and the diseases for the newly settled country...” (VIII) A working tool for current use and to tell the future the tale of how it was.
In contrast to Drake, August Hirsch wrote from the Prussian Society of the 19th century, which was turbulent rather than mobile; the government Bismarck controlled was imperialistic; and the individual had to innate rights and few privileges. Man was as Ackerknecht says, “Chained to a class and paralyzed by traditions of submission.” The Handbuch reflects this rigid culture by ignoring it. Barbu points out that people living in times of stress or social insecurity...” (Have an) abstract, detached and cold quality in (their) perception of the world. Hirsch’s style is cold and abstract; in describing epidemics occurring where he lived, he shows no special empathy; he spent two winters in Russia studying the cholera epidemic of the 1870’s but no personal impression filter through his account in the 2nd edition. Barkhaus though calling the Handbuch a gold mine adds, “but like the other kinds of mining, working through the erudite German’s treatise is no pleasure”...he had no elegance of style...” (2104) and no personal coloring relieves the solid orderly arrangement of fact.
Hirsch’s method of research is also impersonal. With gawky, Lincolnesque legs Drake measured his territory. Hirsch in the rigid university tradition retreated behind the shelves of his books and reviewed the literature. He exhausted all available literary sources, say Virchow, actually quoting more periodicals in the Handbuch than his contemporaries had even seen.
Hirsch allowed his labor to be published with hesitancy and only upon Virchow’s urging and under Virchow’s patronage did the first edition appear. It was a fearful thing to propose a new discipline but that was his purpose and he felt it necessary to defend his motive by showing the practicality of the science. As a recent historian of the discipline of epidemiology says; Hirsch’s work and his terms, historical and geographical pathology is a good substitute. The popular historian, Barbara Tuchman has similarly described the Prussian society of the period; “Society, owing to the lack of intercourse between its rigidly maintained categories, was stiff and dull. Unless ennobled by a von, businessmen, merchants, professional men, literary and artistic people were not hoffahig, that is, not received at court and did not mix socially with the nobility. Nor did they mix among each other. Every German belonged to a Kreis, or circle of his own kind whose edges were not allowed to overlap those of the next one. The wife of a Herr Geheimrat or Herr Doktor did not speak to the wife of a tradesman, nor she to the wife of an artesian. To congregate or entertain or marry outside of Kreis borders invited disorder, the thing Germans feared most. Perhaps to compensate for social monotony, some Germans, according to one report, ate seven meals a day.” (P.303)
There are several basic structured differences between the Systematic Treatise and the Handbuch. First, Drake’s work was limited in space – the Interior Valley of North America, while Hirsch’s work covered the whole world. Second, Drake separated his geographical description of the areas from the diseases-devoting 700 papers to the former. Hirsch combined the geographic conditions found with diseases and did not attempt to detail the ecology of the world- a formidable task. Third, as we will see in the comparisons of the sections on malaria, Drake presented all the ______________ theories on the etiology of disease, its clinical signs and the various therapeutic theories. Hirsch included no clinical information, for he did not intend his work to be used as a practical tool for physicians as did Drake.
In their report on a common topic the difference in approach used by Hirsch and Drake can be exemplified. Malaria is the first disease chosen by both. It is an appropriate one for study as its etiology depends upon geographic factors, and in the knowledge of its cause and cure both Hirsch and Drake remained innocent.
Drake, who rejected the name malaria, preferring autumnal fever, because that implies no specific etiology, described it in both Book One and Book Two of the Systematic Treatise. In the 700 page Book One, which is on the topographic, hydrographic, climatic, geologic and social features of the six million square miles of the intermontane plains, Drake includes the occurrence of autumnal fever and yellow fever in each area under each condition, geologic and climatic so the reader will correlate disease to topography. Autumnal fever’s etiology, occurrence, clinical description, diagnosis and therapy is given in the first part of the second Book on some 170 pages. A reprinting in Volume 2 of this 170 page clinical section was done by Drs. Hanbury Smith and F.G. Smith when they edited this volume after Drake’s death.
Divided into eight chapters, three, about 30 pages, describe autumnal fever etiology, geographic occurrence and history; the remaining five, some 140 pages, are on symptoms, variations and therapeutic details. Despite the many forms that autumnal fever took, intermittent, remittent, it had, Drake emphasized only one cause. Though he reviews the three theories being expounded, mismatic gases, microscopic beings, or atmospheric electricity (716) he draws up some 14 points in support of the 2nd theory, or as he calls it, the vegeto-animalecular theory. His reference to the presence or absence of the mosquito in relation to a sickly or a healthy year, point eleven has often been quoted. Mitchell’s important work on the Crytogamous Origin Fever (1849) was published between the time that Drake finished writing the Systematic Treatise but before it was published, and in a footnote Drake hails it as a great contribution to the vegeto-animalecular concept.
Drake’s clinical description of autumnal fever was accurate; but in a characteristically stubborn and personal manner he refused to subdivide the intermittent and remittent forms by their periodicity, his erroneous divisions-simple, inflammatory, malignant—seemed to him more practical. His therapy was moderate but still unfortunately included bloodletting, purging and puking-though only once in the course of the illness. Never does he advocate, as he quotes a contemporary “bloodletting enough to float or calomel enough to freight the Steamboat Jackson.”
The long portion devoted to clinical detail quickly became obsolete and would have no more than curiosity value today if Drake had not added the therapies employed from time of settlement to the 1840’s,by physician after physician from the mouth of the St. Lawrence to the mouth of the Mississippi. By this he demonstrates the increasing size of the doses of quinine and calomel administered as one travels from north to south, and he speculates the gradual moderation in the drastic practices of bleeding and purging, as one goes from the south to the north.
This was Drake’s method; first, a topographical foundation; then disease by disease, the clinical aspects, changes under different geographical conditions, the therapy, for each section always an analysis and interpretation. If the facts available are not of significant bulk, Drake, always a critic, makes a note: “A summer temperature of 60 degrees is necessary to the production of the fever,” but he carefully adds “the number of observations made in the proper region, is too small to justify a positive conclusion.” (173) Sixty years later, in 1911, Deaderich refers to this conclusion of Drake’s, commenting that only “recently has it been determined that 60 degrees is the lowest temperature at which the parasite can develop in the mosquito.” Drake never forgets to remind the reader of the philosophical premise from which he writes “A synthesis of varieties and races is going on; and the result, I may here repeat, must be a new national constitution, physical and mental.” (701)
Hirsch like Drake chose malaria to begin the Handbuch in his 1st edition but places it 5th in the 2nd edition; the number of pages devoted to it in both, about 55 pages, is about one-third the space Drake devotes to it. Following the definition of malaria, Hirsch reviews its general geographic distribution or location in space; its historical occurrence of location in time; the geographical occurrence of each form – remittent and intermittent, occurrence in races and acclimation, then notes the influence of climate (heat and rainfall), altitude, geology (with six pages on soil), exceptions to general occurrence such as ship malaria, and finally the “malarial poison”. With all the world and all of man’s functional and infective diseases as his subject, Hirsch eliminates clinical signs and therapy. Geographic details are not given a separate section, and the details included are limited to those significant in a disease occurrence or absence.
The most valuable sections on malaria in the first 30 pages—the occurrence of malaria in time and its occurrence in space. The coherent mapping of varied sources into a general picture of malaria distribution is a remarkable feature. “The areas housing malaria on the North American Continent are the Coastal States on the Gulf of Mexico, the prairies of the Western States and a part of the Great Lakes States.” (p.11) The historic occurrence, endemic and epidemic, is traced from 16th century Europe, country by country, era by era. The extensive bibliographies in both editions, but especially the collection on the 15 packed pages of 1800 items in the second edition are unsurpassed.
A single cause for all forms of malaria, Hirsch doubted in the 1st edition: “either there are as many poisonous elements as there are different forms or that malaria is capable of certain modification.” He missed Mitchell’s book though Drake had referred to it. Not until the 1880’s, in his 2nd edition, 30 years after Drake, does he come out emphatically for the “parasitic character of the disease,” and then gives “Mitchell credit for first approaching the theory in a scientific character.” (288)
Although organizing the overwhelming facts and pieces of fact into a coherent picture he did not try to interpret this picture. Unlike Drake, and more noticeable unlike his friend Virchow who used a report on the typhus epidemic in Upper Silesia in 1848 to castigate the prevailing social and political systems, Hirsch never gives a philosophic premise. “As a medical geography,” Barkhaus says, “in the sense of an attempt at elucidating first principles, Hirsch is disappointing.”
Both Hirsch and Drake were medical editors and reviewers, both were widely read, did they know each other’s work? Drake died shortly after Hirsch’s first extensive article which was on malaria appeared, 1848, and no evidence can be found of an English abstract. However, reviews of Drake’s Treatise appeared in Schmidt’s Jahrbrucher in 1852 by both Hirsch and Heinrich Neumann, the German psychiatrist who applauded Drake’s thoroughness and meticulous organization of massive details, usually thought to belong to German works, and he adds, it is dampening to German vanity to see such a work by another author. Hirsch begins his report by referring to Neumann’s review of Drake’s “classic work” and continues, “We must point out that the Treatise is a considerable phenomena in the department of medical geography.” Citations to and quotations from the Treatise occur over 80 times in the Handbuch, volume one, first edition; in the table of the epidemics of yellow fever, Drake is cited as the authority for 40 epidemics. Yet in the introduction to the 2nd edition where Hirsch lists the important early works on geographical and historical pathology he does not include the Systematic Treatise.
During the past century other writers on medical geography, epidemiology, malaris and medical history have used the Treatise and the Handbuch. Medicine geographers, epidemiologists, including those only interested in malaria have gone to Hirsch for historical background; as Barkhaus says “few research experts have to furnish their manuscripts with a “historical” introduction have gone further than the three huge volumes on which Hirsch’s fame rests.”
Davidson in his Geographical Pathology, 1892 is typical; he used Hirsch heavily, calling the Handbuch a “moment of scholarly research” He does not mention Drake although he actually quotes the Treatise once and uses one of his tables. Greenwood, Lombard, Clemow, Solly, Scott, Moulton, Winslow, Hackett, Gill, Boyd, and May repeat this pattern. Parker, Manson, Simmons, and Bordier use neither. Deaderich in A Practical Study of Malaria, 1911, is an exception, he is familiar with both Drake and Hirsch.
The insistence today upon the use of primary source material in historical research has enhanced the importance of Drake’s Systematic Treatise. In the general medical histories of Garrison, Guthrie, Majors, Castiglione, Drake and the Treatise receive marked attention, while Hirsch is either omitted or only mentioned in passing. Singer and Underwood prove like Deaderich that exceptions always exist; they mention both German editions and the English translation of Hirsch’s but do not make any of Drake.
Modern historical studies on areas covered by both men, such as Ackerknecht on Malaria, Long on the Decline of Infectious Diseases and Chalmers on Cholera, Drake is considered the “classic contemporary source”, while Hirsch is cited only as a bibliographic guide.
Many factors contributing to this pattern of use: Drake’s Treatise, was his final work, it has never been re-edited, reissued or revised and as a volume is increasingly rare. Hirsch, only 41 when he signed the Preface to the Handbuch, saw it through a greatly expanded second edition in the 1880’s, and a translation into English of the 2nd edition has made it available in two languages. Although a large portion of both works became obsolete as the laboratory sciences developed, their value to historians has never wavered.
Drake’s hope for the Treatise’s use as a reference tool for diagnosis and therapy by his contemporaries was doomed by the changes in science and the physical and intellectual bulk of the volumes, which forbade ready reference to them. In providing a comprehensive picture of the Valley for the future to see the growth and understand the origin of the new world, Drake know he had succeeded though the range of subjects he enumerated in his title proved too great; the occurrence of diseases in all races was never finished, only the Caucasian is included. Surprisingly, geographical descriptions of some areas which are included in his Traveling Editorials, published regularly in the West Journal of Medicine and Surgery are also omitted.
Hirsch’s aim to justify historical geographical pathology as a discipline of practical importance failed as did Drake’s clinical aim because the discovery of the bacterial origin of disease seemed to render environment unimportant. By his critical examination of existing printed fact and the organization of facts into a general survey of disease distribution, he created a major bibliographical reference tool. The organization of his mind in his rigid environment, however, did not allow him to take the risky steps of interpretation that Drake’s free inventive culture encouraged.
The aims of both were broad and achievements great. To paraphrase Thomas Mendip: They attempted to analyze the matter of their world: A magnificent intention.