The Age of Reason encouraged experimentation, but the first systematic attempt to tie reason to scientific knowledge did not occur until the Age of Enlightenment (18th century). At that time, doctors clung to their superior position over patients by virtue of advanced knowledge and reason — a position held only so long as proposed medical treatments were effective. In some instances, however, new medical treatments were not suggested by physicians but by patients who had the power to override consent and force experimentation on unwilling subjects. A case in point is smallpox.
The Deadly Spread of Smallpox
According to Geddes (2006), the origins of smallpox are unknown, although evidence of the virus has been detected in Egyptian mummies dating back over 3,000 years. Smallpox did not reach Europe until the 6th century, where it continued to spread as populations grew and migrated. By the 18th century, Dinc and Ulman (2007) estimate that smallpox claimed anywhere from 200,000 to 600,000 victims a year in Europe. About 80% of all deaths occurred in children under five years of age.
Ancient Chinese medicine developed a form of nasal inoculation against smallpox that was mildly effective. Eventually, the technique was modified so that it could be applied under the skin, and this improved skill was passed first to practitioners in Russia and then to Balkan countries such as Turkey.
Lady Mary Wortley Montagu and Variolation
In 1717, Lady Mary Wortley Montagu (1689–1762) accompanied her husband to Turkey, where he had been appointed English ambassador. While there, she witnessed an inoculation against smallpox performed subcutaneously, which made a profound effect on her. In a letter published posthumously, Lady Montagu (1796) described how a female healer brought a “nut-shell full of the matter of the best sort of small-pox” and asked the intended subject to select a vein. The vein was opened so that the smallpox could be inserted with a needle, and then the wound was sealed. Although pustules formed on the skin within a few days, a full outbreak of the disease did not occur. To Lady Montagu, the result was astonishing: “Every year, thousands undergo this operation, and the French Ambassador says pleasantly, that they take the small-pox here by way of diversion, as they take the waters in other countries.”
Lady Montagu decided to have her son inoculated against smallpox, and the procedure was a success. As the smallpox virus was ‘variola,’ the procedure was called ‘variolation’ because it referred to the deliberate infection of a person with smallpox.
Enthusiastic about variolation, Lady Montagu became determined to bring the treatment back home with her. She was pessimistic as to whether she could persuade the medical profession to adopt a new therapy that threatened, if successful, to decrease their income: “I am patriot enough to take the pains to bring this useful invention into fashion in England . . . if I knew any [doctors] that I thought had virtue enough to destroy such a considerable branch of their revenue, for the good of mankind.”
Lady Montagu Goes to War
Upon her return to England, Lady Montagu vowed to go "to war" with the medical profession over variolation. Not unexpectedly, she met with stiff resistance from the College of Physicians, who resented any non-licensed individuals giving medical advice. Undeterred, she succeeded in attracting the interest of Princess Caroline of Wales (daughter-in-law to King George I) in the procedure.
In 1721, during a serious outbreak of smallpox, Caroline persuaded George I to arrange a public experiment. In a monarchy, the king was said to own the lives and bodies not only of prisoners, but of orphan children living in parishes under his control. Thus, a king could command experimentation without seeking the consent of his subjects.
Caroline suggested that variolation should be tested on 6 condemned criminals in Newgate Prison; if they lived, the criminals would receive a Royal pardon. In addition, 11 charity children in St. James’ parish were arbitrarily selected as volunteers. All but one of the 17 subjects came down with a mild case of smallpox, and all of the infected subjects fully recovered from the experiment.
Variolation Proven a Success
Even though the public trial was a success, variolation was not infallible. According to Dinc and Ulman (2007), almost 900 people had been inoculated using the Turkish technique by 1729, and 17 of those had died. Thus, approximately 2% of people inoculated through variolation died from infection.
Among the supporters of variolation was the French philosopher Voltaire. In 1753, he declared: “Thirty years ego [sic] I declared that a tenth part of the nation might thus be saved” by variolation, if only people were willing to experiment and try new medical techniques that had proven successful elsewhere. Although Lady Montagu was criticized for pushing a new therapy that was still experimental, variolation continued to be used until Edward Jenner developed a safer vaccination technique in 1798.
In retrospect, it is difficult to escape the suspicion that the criticism aimed at Lady Montagu had more to do with her gender than with the 2% failure rate of variolation. After all, according to Lie et al (2006), an HIV vaccine with only a 60% success rate is sufficient to be approved as a public health treatment against AIDS. Nevertheless, the ethical questions raised by success would linger and haunt experimentation on humans for centuries to come.
References
Dinc G, Ulman YI. 2007. The introduction of variolation ‘A La Turca’ to the West by Lady Mary Montagu and Turkey’s contribution to this. Vaccine. 25:4261–4265.
Geddes AM. 2006. The history of smallpox. Clinics in Dermatology. 24:152–157.
Lie RK, Emanuel EJ, Grady C. 2006. Circumcision and HIV prevention research: an ethical analysis. The Lancet. 368:522–525.
Montagu LMW. 1796. Vol. 1. Letter 36 to Mrs. S.C. from Adrianople, n.d. In: Letters of the Right Honourable Lady M--y W--y M--e: Written During her Travels in Europe, Asia and Africa. . . . Aix: Anthony Henricy.
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