Ever since the introduction of the smallpox inoculation in 18th-century
Europe, physicians and patients alike have grappled with questions of individual
risk, public health ramifications, and balancing the interests of the individual
and the state. Adoption of such a preemptive measure rested historically on
a calculation of risk fraught with unknowns and uncertainties; eg, risk of
infection vs risk of prophylaxis. In spite of mathematical demonstration of
the safety and efficacy of inoculation for the community as a whole, public
trepidation prevented its general acceptance in 18th-century France, highlighting
the sometimes divergent interests of the individual and the state.
A new form of medical knowledge—the statistical assessment of
risk—emerged from the 18th-century French smallpox inoculation debate.
After almost 2 decades of limited success in persuading the French to inoculate
by highlighting the procedure's successful practice in Turkey, China, and
England, the philosophes, the leading philosophical,
political, and social writers of the French Enlightenment, made a mathematical
argument for inoculation. In April 1760, Daniel Bernoulli offered France's
Royal Academy of Sciences the first mathematical theory of the propagation
of an infectious disease.1 Convinced that
mathematics provided normative evidence that would compel individuals to inoculate,
Bernoulli developed formulas for the propagation of smallpox and for the benefit
that universal inoculation would provide. He concluded that the universal
practice of inoculation would increase life expectancy at birth by 2 years
and 2 months.2 Given the net benefit that
inoculation afforded the individual and society, Bernoulli posited that rational
individuals would inoculate, despite the 1-in-200 risk of perishing from the
procedure. Yet much to the surprise of Bernoulli and his fellow philosophes, the French continued to eschew inoculation.
In his 1767 book, New Reflections on the Practice
of Inoculation, the Italian physician Angelo Gatti captured what had,
for 2 decades, thwarted Bernoulli's and the philosophes' efforts to promote
voluntary adoption of inoculation. Gatti argued that without complete assurance
of its safety, inoculation would never be widely practiced. The inoculation
decision entailed a calculation of risk—the guaranteed risk of a mild
case of inoculation-induced smallpox in the near term vs the uncertain probability
of contracting natural, more virulent smallpox in the future. Challenging
the philosophes, Gatti contended that individuals
did not view medical risk through the lens of mathematical calculation. Echoing
the arguments of the encyclopedist Jean le Rond d'Alembert, Gatti emphasized
the paramount influence of the individual's subjective, psychological experience.
The risk of death in the short-term from the inoculation had a paralyzing
psychological effect. Gatti wrote, "An immediate risk, no matter how slight,
will always make a greater impression than a very great, but distant and uncertain
one."3 Concerned primarily with self-preservation,
no individual wished to be the 1 in 200 to perish from the inoculation. In
practice, Gatti argued, people evaluated inoculation based not on statistics
but on perception of its costs and benefits, the value one placed on one's
own life, and the quality and type of life to which one aspired.
Although the French medical community had not led proinoculation efforts
in the 1750s, by the 1760s, the corporation of physicians was perceived as
the sole entity capable of persuading the public to inoculate. Inoculation
advocate Père d'Entrecolles wrote, "The public awaits . . . the competition
between the luminaries [in the Faculté de Médecine]; its decision
without a doubt will put an end to all the disputes that have been raised
concerning [inoculation.]"4 The philosophes
believed the medical community could quell the psychological, subjective concerns
that impeded inoculation by attesting to inoculation's safety and efficacy.
Yet the French medical establishment was hardly a natural ally of the philosophes.
The procedure necessitated a shift in physicians' conceptions of their role,
rendering them purveyors of disease as well as healers, since inoculation
entailed introducing viral matter from the pus of a virulent smallpox. Within
7 to 10 days, the inoculee fell ill with a mild form of the disease.5 Moreover, physicians acted cautiously, cognizant
of their limited understanding of smallpox's etiology and the inoculation's
impact. Into the 1770s, physicians expressed concern as to whether inoculation
provided lifelong protection against contracting smallpox, whether inoculees
spread natural smallpox, and whether inoculation-induced smallpox (known in
the 18th century as "artificial smallpox") was less virulent than natural
smallpox. Simultaneously, physicians faced a demanding and emotionally charged
public who labeled as "murderers" those who lost patients to inoculation and
yet accused physicians who refused to inoculate of complicity in thousands
of deaths.6,7 The public's
demand for action in a situation in which the public good was poorly defined
placed tremendous pressure on the deliberative, consensus-oriented culture
of the 18th-century French medical guild.
A severe, protracted, Parisian smallpox epidemic in the winter of 1762-1763
forced the French medical community to the forefront of the inoculation debate.
France's leading court, the Parlement de Paris, issued an order halting the
practice of inoculation and requesting that the Paris Faculty of Medicine
rule on its efficacy and safety.8 The Parlement's
response to public perception that inoculation had contributed to the outbreak's
severity galvanized the medical community. A debate within the medical faculty
ensued in late summer 1764. For more than 2 hours, Guillaume-Joseph de L'Epine,
leader of the anti-inoculation physicians, enumerated the arguments of inoculation
advocates and then refuted each of them.9 His
discourse focused on safety: inoculation must be avoided because it could
result in death.
The following week, Antoine Petit delivered a comparatively brief address
in favor of tolerating inoculation. Like de L'Epine, Petit focused on the
safety and efficacy of inoculation, but he reached the opposite conclusion.
Inoculation should be tolerated, provided that successful inoculation prevented
recurrence of the disease and as long as artificial smallpox remained less
dangerous than natural smallpox. Petit cited reason and historical example
to justify his position. If inoculation did not work, it would not have been
practiced for centuries in Turkey and Asia, nor for decades in England.10
In addition to emphasizing the safety and efficacy of inoculation, Petit
argued that inoculation was in the national interest. Echoing the statist,
Bernoullian perspective, Petit contended that universal inoculation would
be an unalloyed good, fueling economic growth and affording protection against
depopulation.11 In an era when demographic
strength was perceived as imperative to France's status as a European power,
inoculation, by reducing the smallpox mortality rate from 1 in 7 to 1 in 200,
offered the state a substantial advantage. As Petit wrote, "And if one sees
in the future, the uncountable posterity, that will be born of men saved by
Inoculation, one must also see, that if there were a European nation that
adopted inoculation of its children, while its neighboring peoples rejected
it . . . that nation [which does not inoculate] will find itself fatally weakened
and others will subjugate it without difficulty."10
Despite the proinoculation physicians' recognition of inoculation's
benefit to the individual and the state, Petit and his colleagues stopped
short of advocating its universal adoption. Petit acknowledged that the medical
community was reluctant to mandate use of a new prophylactic that might ultimately
be discredited, bringing opprobrium on physicians. Yet, more significantly,
Petit and his colleagues argued for the primacy of individual and family choice.
They believed that third parties, even licensed physicians, should not impose
their views on inoculation on patients; the decision to use a potentially
deadly prophylactic should be reserved for the patient and his family. Petit's
colleague Gatti likewise noted that the inoculation decision should be made
by the individual or, in the case of the minor, by the next of kin.
Rather than using its professional authority to influence royal policy
by recommending universal adoption or prohibition of inoculation, the medical
community joined the philosophes in educating the public, thus facilitating
informed patient decision making. Medical and lay journals published hundreds
of articles on smallpox and inoculation between 1755 and 1775. Physicians
recounted successful inoculations of celebrities—foremost among them
the inoculation of the children of Duc d'Orléans in 1756—and
even of their own children. While emphasizing the safety, reliability, and
peace of mind provided by inoculation, physicians empathized with the agonizing
decision facing potential inoculees. The medical community understood the
personal, familial nature of the inoculation decision because physicians perceived
they were in an analogous position vis-à-vis their patients as parents
were vis-à-vis their children. Both wrestled with how to balance the
risk associated with inoculation with the guilt that might ensue should a
noninoculated individual succumb to natural smallpox.
By respecting the sentimental considerations associated with inoculation
and by reinforcing that inoculation should be a personal and familial decision,
the medical community legitimized sentiment as a rational basis for objecting
to inoculation. The physicians revealed the limitations of statistical assessment
of risk in shaping public perception by highlighting the myriad ways in which
individuals might act when confronting medical risk. In doing so, they also
helped expose the fragile foundations of the French inoculation campaign predicated
on voluntary participation and a naive belief that inoculation was always
in the best interest of both the individual and the state. Yet in failing
to resolve the competing and often conflicting interests of national welfare,
public health, and individual choice, the 18th-century French medical community
ultimately did not advance the proinoculation cause. Indeed, the French did
not widely embrace prophylactic measures against smallpox until Jenner's safer
cowpox vaccination technique superseded inoculation in the 19th century.11
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