In the spring of 1768, as the snows melted in St Petersburg, warmer days brought a deadly threat to the Russian capital. A fresh epidemic of smallpox, the most virulent disease on the planet, swept into the city, striking down inhabitants of all ages and every social level. This ‘speckled monster’, fatal in at least a fifth of cases and disfiguring other victims, advanced among the spires and shining domes, unchecked even at the gates of the Winter Palace itself.
Catherine II, Empress of Russia, watched the virus’s assault with dread. Already in hiding from its clutches in her estates outside the capital, she snatched her son, Paul, to her side when smallpox killed the young fiancé of his tutor, her advisor Count Nikita Panin. With Panin’s support, she took a momentous decision: she would protect her son using a cutting-edge scientific process that most of her subjects regarded as deeply dangerous and potentially fatal. She would have Paul inoculated, and she would go one step further: she would first undergo the preventative procedure herself.
Inoculation, often misunderstood today, meant metaphorically fighting fire with fire. It involved giving healthy individuals a minute dose of the smallpox virus (usually by placing a drop of infected matter into a tiny puncture in the arm) to deliberately induce a mild version of the brutal disease and confer lifelong immunity. Later, at the very end of the 18th century, the Gloucestershire doctor Edward Jenner would prove that inoculation using the far milder cowpox virus could also produce immunity to smallpox. The modified process, swiftly dubbed vaccination after ‘vacca’, Latin for cow, would become an unparalleled medical success story, saving millions of lives globally and ultimately leading to the eradication of smallpox.
Vaccination, though, would not have been possible without inoculation. And, in the 18th century, the centre of inoculation technology was Britain. Accordingly, it was to her ambassador in London that Catherine turned in her quest for an expert inoculator to treat herself and her son. Count Mussin-Pushkin, in turn, recruited the man to whom the Empress would entrust her life.
The Empress and the English Doctor tells the remarkable and barely known story of the inoculation of the Empress of Russia and her son by Thomas Dimsdale, a Quaker-born physician from a hamlet outside the town of Hertford. It’s an account of international cooperation, trust, friendship, female leadership, and the battle for science and reason over superstition and misinformation. Those weighty themes emerge from a thrilling tale of profound risk, failed experiments, secret visits to the Winter Palace under cover of darkness, and diplomatic anxiety reaching as high up as King George III himself.
Some 1,700 miles lay between Thomas’s country home and Catherine’s glittering palace on the Neva. The doctor’s journey pitched him into a strange and challenging land he described in colourful letters home to a friend in London. The book, written using Dimsdale family papers including Thomas’s medical notes and the revealing health questionnaire personally filled in by the Empress, closely follows his remarkable experiences, but also explores the forgotten medical history that placed Britain at the forefront of inoculation practice.
Inoculation, long used in varying forms in parts of Africa and Asia, was introduced in Britain from Turkey in the early 1720s, primarily through the efforts of the brilliant and well-connected aristocrat Lady Mary Wortley Montagu. While living in Constantinople with her ambassador husband, Mary witnessed smallpox ‘parties’, where elderly women inoculated groups of children with a blunt needle and drops of pus carried in a walnut shell. Immediately recognising the lifesaving potential of the procedure, she had her own son treated, then returned to London where she convinced leading physicians to witness her daughter’s inoculation and persuaded many elite parents – including the Princess of Wales, Caroline of Ansbach – to follow her example.
Mary’s influence, together with two reports on inoculation in Turkey published by the Royal Society, established the practice in Britain, though a backlash began instantly. Exactly 300 years ago, in 1722, the Royal inoculations prompted fury among critics, who argued God used illness to punish sin. The first ‘anti-inoculators’ (forerunners of today’s anti-vaxxers) questioned the logic of deliberately taking an upfront risk, however small, to avoid a far greater risk that might yet be avoided.
The same debates, as the Covid era has shown, have ricocheted down the years, but Britain was first among European countries in actively pursuing and officially recognising the new procedure. The Royal Society played its part by crowdsourcing from practitioners evidence of the mortality rate of inoculation, comparing their figures with the fatality of ‘natural’ smallpox – and pioneering the use of mathematics to assess a medical procedure. The new technology led to the death of around one in 50 patients, while the full disease killed one in five. Just as Chris Whitty’s famous slides have shown with the Covid vaccination, the safety data came down firmly on the side of inoculation.
The practice became increasingly common in England, particularly as virulent smallpox epidemics swept the country. The new London Smallpox Hospital opened in 1746, serving as a centre of excellence visited by doctors from across Europe, and in 1755 the Royal College of Physicians gave inoculation its official stamp of approval, branding it ‘a practice of the utmost benefit to mankind’. No other country was as open to the technology, or as willing to put aside philosophical debates and simply embrace inoculation’s effectiveness. Across the Channel in France, the Church and conservative medical profession resisted the practice, much to the frustration of intellectuals such as Diderot and Voltaire – an energetic supporter of both Catherine and inoculation. For the philosophes, the procedure represented a truly enlightened scientific breakthrough, relying not on inherited dogma or theory but on observation, experience and reason.
While English physicians had embraced inoculation, their training in humoral medicine had nevertheless prompted them to amend the simple methods used in Turkey. In place of a minute needle prick, they made deep incisions and placed pus-soaked threads inside, risking infection, and kept patients dangerously warm to sweat out fevers. The technology’s next advance came in the early 1760s, when a Suffolk doctor called Daniel Sutton stripped the procedure back almost to its original simplicity, inserting a tiny drop of infected matter via the smallest puncture, minimising complex preparation involving purging and special diets, and ensuring inoculees stayed cool as they recovered. The entrepreneurial Sutton kept his methods secret, but Thomas Dimsdale, an experienced and highly respected inoculator, rapidly worked them out and trialled them on his own patients. Finding the process was significantly safer, quicker and more pleasant, Thomas made it available to all, publishing in 1767 The Present Method of Inoculating for the Smallpox. It was this highly successful treatise, soon translated into four languages and running into seven editions, that drew him to the attention of the Empress of Russia.
In the hands of a careful practitioner, the ‘new’ method of inoculation (essentially a return to the old Turkish technique) was remarkably safe. Many modern accounts of vaccination write off its foundational technology as risky and unsophisticated, but Daniel Sutton successfully inoculated tens of thousands of patients and Catherine often boasted that Thomas had treated 6,000 individuals and lost only one child who was already sick. The key drawback of the procedure was the fact that patients were briefly infectious and could spread natural smallpox if not kept isolated. When the Empress reached the fifth day of her own inoculation, she and Thomas ensured she was kept away from the nobles who constantly surrounded her. To her anxious physician’s overwhelming relief, the distinctive pustules soon appeared on her skin, and she made a swift recovery.
Catherine used her own example to promote inoculation across her empire, commissioning a ballet and poetry to mark the event, ringing church bells, firing cannons and even launching an annual public holiday. Outside of Russia, she boasted of her experience to underline her own credentials as an enlightened ruler and her country as a forward-looking European state rather than a primitive backwater. Her efforts could not overturn widespread suspicion of inoculation, but new hospitals treated thousands of patients and, when Jenner proved the smallpox-vanquishing power of cowpox in 1798, Russia was ready to adopt vaccination with remarkable speed.
Thomas, richly rewarded by the Empress, maintained a lifelong friendship with his patron, exchanging gifts and even returning in 1781 to inoculate her grandsons Alexander and Constantine. In England, he used his fame to campaign for free access for the poor to inoculation, arguing for more hospitals and the use of incentives such as new clothing to encourage the wary to take up the offer of a jab. Inoculation by now was less a matter of medical methodology than of public health: inoculators – including Thomas – used their experience to deepen their understanding of contagion, and began to glimpse the extraordinary possibility that the smallpox virus might be entirely eradicated.
Jenner’s landmark discovery came just two years before Thomas Dimsdale’s death in 1800. Thomas’s reaction is not recorded, but the teenager he had inoculated in Russia, Catherine’s son Paul, had by now inherited his mother’s crown and quickly set about bringing vaccination to Russia. Jenner stood on the shoulders of many early inoculators and the campaigners, such as Catherine the Great, who believed in them. Their crucial role in the development of vaccination deserves to be remembered.
Lucy Ward is a writer and former journalist, and the author of The Empress and the English Doctor: How Catherine the Great defied a deadly virus.
Aspects of History Issue 13 is out now.