2. A Political Consciousness Compared with the medicine of species, the notions of constitution, endemic disease, and epidemic were of only marginal importance in the eighteenth century. But we must return to Sydenham and to the ambiguity of what he has to teach us: in addition to being the initiator of classificatory thought, he defined what might be a historical and geographical con- sciousness of disease. Sydenham's 'constitution' is not an autonomous nature, but the complex--a kind of temporary node--of a set of natural events: qualities of soil, climate, seasons, rain, drought, centres of pestilence, famine; and when all these factors do not account for henomena, there remains no clear species in the garden of disease, but an obscure nucleus, buried in the earth: 'Variae sunt semper annorum constitutiones quae neque calori neque frigori non sicco humidove ortum suum debent, sed ab occulta potius inexplicabili quadam alternatione in isis terrae visceribus pendent' [1]. The constitutions hardly have symptoms of their own; they define, by displacements of accent, unexpected groups of signs, phenomena of a more intense or weaker kind: fevers may be violent and dry, catarrhs and serous discharges more frequent; during a long, hot summer, visceral congestion is more common and more tenacious than usual. Of London, between July and September 1661, Sydenham says: 'Aegri paroxysmus atrocior, lingua magis nigra siccaque, extra paroxysmum aporexia obscurio, virium et appetitus prostratio major, major item ad paroxysmum proclinitas, omnia summatim accidentia immanioria, ipseque morbus quam pro more Febrium intermittentium funestior' [2]. The constitution is not related to a specific absolute of which it is the more or less modified manifestation: it is perceived solely in the relativity of differences--by a gaze that is in some sense diacritical. Not every constitution is an epidemic; but an epidemic is a finer-grained constitution, with more constant, more homogeneous phenomena. There has been, and still is, a great deal of discussion as to whether the doctors of the eighteenth century had grasped its contagious character, and whe- ther they had posed the problem of the agent of their transmission. An idle question, and one that remains alien, or at least derivative, in relation to the fundamental structure: an epidemic is more than a particular form of a disease. In the eighteenth century, it was an autonomous, co- herent, and adequate evaluation of disease: 'One calls epidemic diseases all those that attack, at the same time and with unalterable characteristics, a large number of persons' [3]. There is no difference is nature or species, therefore, between an individual disease and an epidemic phenomenon; it is enough that a sporadic malady be reproduced a number of times for it to constitute an epidemic. It is a purely mathematical problem of the threshold: the sporadic disease is merely a submarginal epidemic. The perception involved is no longer essential and ordinal, as in the medicine of species, but quantitative and cardinal. The basis of this perception is not a specific type, but a nucleus of circum- stances. The basis of an epidemic is not pestilence or catarrh: it is Marseilles in 1721, or Bicetre in 1780; it is Rouen in 1769, where 'there occurred, during th summer, an epidemic among the children of the nature of bilious catarrhal and putrid fevers complicated by miliaria, and ardent bilious fevers during the autumn. This consitution degenerated into putrid biliousness towards the end of that season and during the winter of 1769 and 1770' [4]. The usual pathological forms are mentioned, but as factors in a complex set of intersections in which their role is analogous to that of the symptom in relation to the disease. The essential basis is determined by the time, the place, the 'fresh, sharp, subtle, penetrating' air of Nimes in winter [5] or the sticky, thick, putrid air of Paris during a long, heavy summer [6]. The regularity of symptoms does not allow the wisdom of a natural order to show through as in filigree; it treats only the constancy of causes, the obstinacy of a factor whose total, unceasingly repeated pressure determines a preferential form of disease. It may be a cause that survives in time--being responsible, for example, for plica in Poland and scrofula in Spain--in which cases the term endemic will be more readily used; or it may be causes that 'suddenly attack a large number of people in one place, without dis- tinction of age, sex, or temperament. They appear to proceed from a single cause, but as these diseases reign only for a limited period, this cause may be regarded as purely accidental' [7]: this is so in the case of small- pox, malign fever, or dysentery, which are epidemics in the true sense. It is hardly surprising that despite the great diversity, in disposition and age, of the people affected, the disease shows the same symptoms in all: this is because dryness or humidity, heat or cold, when prolonged, ensure the domination of one of our constitutive principles: alkalis, salts, phlogiston; 'We are then exposed to the accidents occasioned by this prin- ciple, and these accidents must be the same for different subjects' [8]. The analysis of an epidemic does not involve the recognition of the general form of the disease, by placing it in the abstract space of nosology, but the rediscovery, beneath the general signs, of the particular process, which varies according to circumstances from one epidemic to another, and which weaves from the cause to the morbid form a web common to all the sick, but peculiar to this moment in time and this place in space; in Paris, in 1785, there was an epidemic of quartan fever and putrid synochus, but the essence of the epidemic was that 'the bile had dried up in its passages and turned into melancholy, the blood had become impoverished, thickened, and sticky as it were, the organs of the lower part of the abdomen had swollen and become the causes or centres of obstruction' [9], or a sort of over-all singularity, an individual with many similar heads, whose features are mani- fested only once in time and space. The specific disease is always more or less repeated, the epidemic is never quite repeated. --

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