CHAPTER 4Improving Health, Inoculating Smallpox

Climate Critics

One aspect of the ongoing investigations of climate in the eighteenth century involved a theory promoted by some Enlightenment thinkers now called “climate determinism.” This idea suggested that climate influenced not only the constitution of bodies and overall health but also the culture of those people, particularly their political development.⁶ For some French philosophes, Russia served as the ideal model of political development in a cold climate. Siberia's underpopulation and the empire's undeveloped resources provided evidence of the ineffectiveness of the Russian government. An intemperate climate produced an intemperate government, which failed to effectively improve the empire.

The most well-known climate determinist in the eighteenth century was Baron de Montesquieu, who critiqued Russia's climate and its government in The Spirit of Law (1748).⁷ In his view, Russia's cold produced not only its autocracy but also its negative social and cultural consequences. He wrote: “The strength of the fibres in northern nations is the cause that the coarsest juices are extracted from their ailments. From hence two things result: one that the parts of the chyle or lymph are more proper, by reason of their large surface, to the applied to, and to nourish, the fibres: the other, that they are less proper, because of their coarseness, to give a certain subtilty to the nervous juice. Those people have therefore large bodies and little vivacity.”⁸ A nation populated by peoples of little vivacity had been the long-term problem confronting Russia. Warmer climates had always been associated with energy and industry; cold climates produced laziness. According to Montesquieu, cold countries also had “little sensibility for pleasure,” which was the source of their ongoing population challenge.⁹

Aside from the reliance on old tropes of cold bodies, Montesquieu added new details to the implicit challenge of life in the north. Alcohol was necessary for survival: “In cold countries the aqueous part of the blood is very little evacuated by perspiration. They make therefore make use of spirituous liquors, without which the blood would congeal. They are full of humours; consequently strong liquors, which give a motion to the blood, are proper for those countries.” It followed logically that people in hot climates should not drink alcohol, which is why the Muslims in the Middle East abstained. However, “Such a law would be improper for cold countries, where the climate seems to force them to a kind of national drunkenness, very different from personal intemperance. Drunkenness predominates over all the world, in proportion to the coldness and humidity of the climate.”¹⁰

Montesquieu did not offer the only perspective on Russia's challenges during the Enlightenment. Nor was he the only philosophe focused on the problematic government of Russia, given that any intemperate region suffered from some lack in comparison to temperate Europe. Events in Russia, however, soon proved that Montesquieu's criticism of the empire was justified. Hardly a decade after Montesquieu depicted Russia as an empire of “national drunkenness” and “little vivacity,” Tsar Peter III (r. 1762-1763) was overthrown by his wife, Catherine, giving French critics an opportunity to depict the lack of effective leadership in Russia. Claude-Carloman de Rulhière, a young French diplomat in Russia in 1762, wrote a description of Catherine's illegal rise to power. Catherine intervened to prevent the text's publication until after her death, fearing damage to her reputation abroad.¹¹ Russia's ongoing problems were obvious to Rulhière. Once Peter became tsar, he “began his reign by an edict, whereby, in the plentitude of his arbitrary power, he granted to the Russian nobility the rights of a free nation; and as if, in reality, the rights of the people depended upon the concession, the edict produced such violent transports of joy, that this vain nation proposed to erect from him a statue of massy gold.” It was clear that Russia was unprepared to be a modern nation. Catherine and Nikita Ivanovich Panin, who Rulhière considered to be Catherine's primary ally, were “united in the resolution of rescuing their country from despotism.”¹² Rulhière also described at length Catherine's reliance on military force to manage a coup and execute her husband.

Rulhière's depiction of Russia confirmed Montesquieu's argument on the consequences of the climate. Its people were confused by basic concepts of political authority, leading them to accept a government based in despotic control. Peter III accomplished sweeping reforms—but only when implemented by foreigners, who also turned the court into a hotbed of sexual politics. For Rulhière, both sex and politics were foreign accomplishments. The changing medical ideas—the emergence of a neo-Hippocratic tradition—may have been unknown to the general public. Montesquieu's view of the government and its connection to the climatic conditions may have been better known among Europe's educated elite. But Catherine's coup proved Montesquieu's criticism was correct—that the climate created a dangerous country—and Rulhiére offered the proof.

French critics of Russia continued to attack during Catherine's reign. In the 1760s, this included Jean-Baptiste Chappe d’Auteroche, who traveled across Russia to Tobol’sk in Siberia in 1761 to observe the Transit of Venus. The first volume of Chappe d’Auteroche's account was a detailed description of his travel from France to Tobol’sk; the second volume was a series of short essays enumerating Russia's resources, including its minerals, geography, and peoples. Those essays were reliant on the available resources on Siberia, including Eberhard Isbrand Ides, Gmelin, and Strahlenberg. Steller's account of Kamchatka was published as the third volume of Chappe d’Auteroche's account but was left out of the English translation in 1770 because it had already been published there.¹³ Relying on official Russian sources, particularly Ides and Gmelin, as proof of Russia's failure to manage its empire, revealed how dangerous the academy's work could be for the tsar's reputation.¹⁴

When Chappe d’Auteroche assessed “the population, trade, navy, revenues, and land forces of Russia,” he began from a premise that most Enlightened thinkers would accept: “The power of the state arises from its population; altho’ in many countries this circumstance is the least object of the attention of the government. Depravity of manners, luxury, and the wretchedness of the people, are the chief impediments to population; since it is well known, that unlawful connections contribute but little to the propagation of the species.” Russia suffered from all these impediments, in addition to its well-known challenge: “In northern countries, the climate furnishes a fresh obstacle to population: the regions of the Laplanders, of the Samoiedes, and all the northern parts of Russia, have been always depopulated, and will ever be so, because of the unfruitfulness of the soil, and the bad quality of the food these people are obliged to live upon: this food contains hardly any nutritious juice, and all nature in these climates seems to be in a state of perpetual sluggishness, in which scarce any active principles are to be discovered” (figure 4.1). The extreme climate remained a perpetual obstacle. Chappe d’Auteroche also believed the climate reduced the procreative ability of its population, mentioning that “almost all philosophers are of opinion, that the constitution has less powerful influence in the northern, than in the southern climates: the people of the north are less addicted to venery.”¹⁵

Figure 4.1. This illustration of a Samoyed woman and child was included in the French edition of Chappe d’Auteroche's text. In a section highlighting the Samoyed disinterest in procreation, including a child in the image highlighted the issue. “Habit of a Samoyede woman and child subject to Russia in 1768. Femme Samoyèd,” The Miriam and Ira D. Wallach Division of Art, Prints and Photographs: Art and Architecture Collection, The New York Public Library, New York Public Library Digital Collections, accessed June 9, 2024, https://digitalcollections.nypl.org/items/510d47e4-7ef6-a3d9-e040-e00a18064a99.

Echoing the observations of the earlier narratives, Chappe d’Auteroche believed that the Russians overcame the natural disinterest in sex among the people of the empire. He argued: “The Russians an exception to this general rule: and it should seem that this apparent contradiction may be accounted for from moral causes. The women being left to themselves, and suffered to live in idleness, the effects even of their most trifling passions must be powerful. Among the common people, men, women and children lie together promiscuously, without any sense of shame. Hence their passions being excited by the objects they see, the two sexes give themselves up early to debauchery.” Chappe d’Auteroche was as interested in the sex lives of Russia's subjects as any of his predecessors, and he included innumerable details of the Russians’ questionable morality throughout his travels. In Nizhnii Novgorod, for example, he mentioned “The young lads in this town, as well as in the neighbouring places, are married at fourteen or fifteen years of age, and the girls at thirteen: the women often breed ‘till they are fifty.” The reason for the young marriage age was not religious or cultural, but “necessary to marry the girls early, in order to prevent debauchery” (figure 4.2).¹⁶

Figure 4.2. The previous Samoyed woman and child contrast with this Chuvash woman, one of the peoples of “northern Tartary” discussed in Chappe d’Auteroche's text (1757–1772). “Habit of a woman of Wotiac in Siberia in 1768. Femme Wotiake,” The Miriam and Ira D. Wallach Division of Art, Prints and Photographs: Art and Architecture Collection, The New York Public Library, New York Public Library Digital Collections, accessed June 9, 2024, https://digitalcollections.nypl.org/items/42e2e440-c5fc-012f-f3f9-58d385a7bc34.

If the Russians were marrying early, why was the population not larger? Chappe d’Auteroche argued that it was not because of the lack of sexual interest among the Siberian population, but rather the devastating effects of endemic diseases. Three were inescapable: smallpox, syphilis, and scurvy. Together, they “make so much havock in Russia, that unless the government takes some measures to prevent their effects, they will put an end to the human species in this country.” His estimates on the outcome for the population were dire: “The small-pox carries off near one half of the children: this disease seems to have been communicated to this country from Europe”; in other words, Russians introduced and spread the disease across the country. “Venereal disorders are diffused throughout all Russia, and in northern Tartary more than any where else. The men are much addicted to sodomy in Russia. Venereal disorders prevail among all the people from St. Petersburg to Tobolsky.” His evidence for the prevalence of syphilis came from Gmelin, whom he cited extensively as proof of the government's awareness of the condition and its inability to resolve it¹⁷

Chappe d’Auteroche suggested that scurvy was undoubtedly the most widespread disease. His argument followed the accepted idea that cold weather caused putrefaction inside the body: “All the Russians, in general, are much addicted to the scurvy; the languid and inactive life they lead, being shut up in their stoves all the winter, make them very full of humours, and they perspire very little.” Unlike smallpox and syphilis, the Russians’ reliance on the bania provided a solution to the condition, by inspiring perspiration and releasing toxic humors. “They produce a great fermentation in the blood and humors, and bring on plentiful discharges by perspiration. The extreme cold drive the humors back from the skin, and restores the equilibrium again.” What remained a question for Chappe d’Auteroche was why use of the bania had not extended among all of Russia's subjects, preferring the heat of their large stoves over the heat and humidity of the bania. Whereas every Russian “from the sovereign to the meanest subject, bathes twice a week,” Tatars and Siberians preferred the stove. The results were devastating: “The small-pox destroys almost one half of the children, and some times a greater proportion” and syphilis was widespread and “more dangerous here than in any other place, on account of their being usually joined with the scurvy, and that the medicine proper for one of these diseases always increases the other.” Without effective government intervention, these diseases “in the process of time should put an end to the human species in these parts.”¹⁸

Chappe d’Auteroche included Ides's, Gmelin's, and Steller's texts as evidence; few, if any, of his observations were new. His conclusions, however, were. Building on more than a century of travel narratives and the more recent fieldwork by the academy, Chappe d’Auteroche presented a straightforward argument. Russia's inability to treat or prevent its endemic diseases not only led to an underpopulated empire but also threatened to exterminate the remaining population. Russia's failure to develop its natural resources was not a failure of science or engineering, but rather a public health crisis. Notably, other Frenchmen had made similar arguments about France's failures to control its disease burden at the same time, with the exact same consequences on the French populace.¹⁹ If a difference was to be found in Chappe d’Auteroche's criticism, it might have been the timing of it—first critiquing the government for its ineffective rule and lack of concern for its population, and then the truth of Catherine's coup as proof of both problems. An anonymous refutation of Chappe d’Auteroche's text was published in Paris a year after its first edition in 1770, but no Russian official offered any public response.²⁰

Privately, Catherine was not silent on the topic. Chappe d’Auteroche published his travel narrative in a period when Catherine was actively corresponding with other figures of the Enlightenment, including François-Marie Arouet, better known by his pen name Voltaire. Early in 1771, for example, Catherine wrote to Voltaire mentioning the great success she had in hosting the prince of Prussia in St. Petersburg, who admired the city's beauty, unlike “Abbé Chappe, who saw everything in Russia from a closed sledge, in which he travelled post-haste.”²¹ Catherine casually dismissed the idea of Chappe d’Auteroche's accuracy with her comment, suggesting he failed to see Siberia in any sense. Voltaire was a sympathetic audience. In a response to Catherine written later that same year, Voltaire mentioned he enjoyed the refutation of Chappe d’Auteroche's book that had been recently published. Furthermore, he praised the recent publication of Catherine's Instruction in a French translation, “which ought to belong to all the kings and tribunals in the world.” The Instruction had been censored in Paris by “some ill-mannered cur,” but, for Voltaire, that was only further evidence of Russia's superiority to France.²²

Nothing stated by Catherine's French critics was markedly different from the ongoing private conversations throughout her court. The British diplomats, in particular, were strikingly critical of the Russian political system, but Britain, unlike France, remained dependent on Russia's exports, leaving these indictments as private advice provided to the foreign secretary by the ambassadors.²³ George Macartney served in St. Petersburg in the early years of Catherine's reign and described Catherine's court as filled “with the most provoking Phlegm & the most Stoical Indifference.”²⁴ In other words, the people were phlegmatic and melancholic, and therefore disinterested in his negotiations. He continued by suggesting to the British foreign secretary that “you may imagine the Law of Nations can’t have made any great Progress in a Country where there are no such thing as a University. Barbarous as they are & ignorant of those Arts which improve the understanding, enlighten the mind or promote discovery…. Like Children they are allured by every new Idea—pursue it for a moment & then abandon it when another starts up in their Imaginations.”²⁵ Pointing toward Russian ignorance and immaturity only supported Chappe d’Auteroche's publication, but this description was offered by Russia's closest European ally.

Macartney's successor, Henry Shirley, was hardly any kinder. In a dispatch to the foreign secretary sent in 1768, he reported on Catherine's Legislative Assembly, currently meeting in Moscow to discuss potential reforms. It was an explicit indictment: “The manner in which they have hitherto proceeded in attempting so many important affairs & so very difficult, appeared to me so much like a Farce, that it would have been ridiculous to fill up several Sheets with an Account of Things which can only pique, & not interest Our Curiosity, raised by the noisy Flatterers of thos Men who are struck by mere appearances, or who scrape some advantages by offering up Incense to this Idol of the Empress's Vanity.”²⁶ After outlining the combined disaster of Catherine's lack of leadership and the assembly's inability to solve Russia's challenges, Shirley could only offer his regrets: “One cannot help pitying the Russians, who think themselves so wise, so powerful, when they are such an immense Distance from the happy situations of some Nations of Europe.”²⁷ Although Shirley did not explicitly connect the cold climate to the political shortcomings, his assessment of Russia still agreed with Montesquieu's view.

Russia's critics argued that the cold climate was an unavoidable challenge for the bodies and intellect of the empire. It was responsible for the procreative challenge that resulted in an underpopulated state. It facilitated the spread of three endemic diseases that further reduced the population. It is arguable, at least, that following the Second Kamchatka Expedition, the academy, if not the government itself, took steps to finding effective therapies to mitigate, or even cure, both scurvy and syphilis. Even at the time, the results of those treatments were debatable, but the government could make an argument it was aware and working to address two of Chappe d’Auteroche's problems. By the time of his travel across Russia in 1762, however, the other two (smallpox and the low birth rate) were not yet the focus of the academy or the state's attentions. If the Russian Empire was going to improve its health and increase its population, those issues needed to be addressed as soon as possible.

Public Interventions

The Russian Empire was not waiting for foreign critics before intervening to improve the health of the population. Early travelers, and the academy's expedition, had already been investigating conditions inside the empire and recommending actions. The Russian government may have preferred physicians trained in certain schools, but neither the staff nor the curriculum at those schools was stagnant. Medical knowledge was constantly evolving. The first major reform of Russia's education system arrived after Nicolaas Bidloo's death, with the new curriculum designed by Dr. Johann Bernhard Fischer on December 24, 1735. Fischer was born in Lubeck in 1685 and would pursue medicine at Halle, Jena, and Leiden, where he studied with Herman Boerhaave and completed his medical doctorate with a thesis, “About Mania,” in 1705. In 1710, Fischer established a practice in Riga, and was brought into Russia through Peter the Great's conquest of that city. Under Russian rule he prospered, becoming Anna Ivanovna's personal physician in 1735. His reform plan for hospitals was a lengthy document that outlined in detail the responsibilities of each rank of employee as well as the responsibilities of its students. The hospitals would be led by a physician and supported by a head surgeon, five surgeons, ten recent graduates, and twenty surgical students as well as one apothecary.²⁸ The responsibilities of each rank of employee was listed to clarify the relationship between these men and their patients.

Although the treatment of patients was not the primary purpose of this reform, Fischer notably included a table describing the ideal patient's diet while under treatment in the hospital. Bread, meat, and salt were prescribed every day, as well as one mug of beer and one glass of wine. Three times a week, the patients would be served oats, barley would be served once, and butter would be served four times.²⁹ In the eighteenth century, wine was utilized as a safe substance as a base ingredient for pharmaceutical preparations, but the rest reflected an ideal diet more than a specific therapeutic treatment. Later, as the director of the Medical Chancellery, Fischer authored a few books on medical treatments distributed to army surgeons. Between the reform of the hospital schools and his instruction manuals, his advice had a long legacy on Russian medical practice.

Twenty-five years after Fischer's reform, the medical curriculum would be updated again. The first change came from Elizaveta Petrovna's (r. 1741–1762) personal physician, Jean Armand de L’Estocq. Born and educated in Germany, and descended from a French noble family, L’Estocq arrived in Russia in 1709, becoming one of Peter the Great's court physicians and a confident of Elizaveta during Peter's reign.³⁰ L’Estocq was sent into internal exile during Anna Ivanovna's reign, but he returned following Elizaveta's seizure of the throne in 1741.³¹ As archiater, or the head of the College of Medicine under Elizaveta, L’Estocq added a new course in obstetrics as part of the Russian medical curriculum taught at the surgical schools established in Moscow and St. Petersburg in the 1750s.³² This reform preceded the criticism of Russia's birth rate by Chappe d’Auteroche, but certainly this issue had been raised by the fieldwork conducted during the Second Kamchatka Expedition. At first glance, adding obstetrics to the medical curriculum only in the 1750s might have appeared to be a late development, but this was roughly concurrent with its addition to the medical curriculum at the University of Edinburgh, where several other Russian physicians, including L’Estocq's colleague John Cook, were trained. The curricular addition was supported by the state hiring its first two gynecologists, Gotthard Wilhem Reichardt and Andreas Lindemann, in 1757. Both men were born in the Russian Empire, Reichardt in Riga and Lindemann in Reval, but they received their medical degrees in Germany.³³

The addition of obstetrics was not the end of the changes of that decade. L’Estocq's successor as archiater, James Mounsey, passed further revisions. Mounsey studied medicine at the University of Edinburgh, but did not graduate, instead becoming an apprentice to a local surgeon, Thomas Wood. In 1736, he entered Russian service, first working in the St. Petersburg Admiralty Hospital and then serving in the army in Ukraine. He would then receive his medical doctorate at the University of Reims, France, before returning to Russia in 1741, where he returned to army service. By 1756, he was sufficiently well known among Russia's elite to be sent by Elizaveta Petrovna to care for Ernst Johann Biron's wife. Following the death of Elizaveta's court physician, Mounsey became the new court physician and a state councilor in 1760. Following Elizaveta's death the following year, Tsar Peter III promoted Mounsey to archiater.³⁴

Shortly after his new appointment, Mounsey issued two significant changes to the operations of the medical establishment. The first was a set of guidelines to recognize medical service in parallel with the existing Table of Ranks, so that medical practitioners could advance through the social system following similar guides for the army or navy, which was approved by the Senate in February 1762. The second was an “Instruction to All Doctors on the Discharge of Their Duties,” which was signed by Peter III and approved by the College of Medicine on April 30, 1762. This instruction added an incentive for doctors that could “describe, draw and collect animal vegetable or mineral specimens of natural history or materia medica, particularly in remote areas.”³⁵ In other words, it was a formal directive to continue the work begun by Daniel Gottlieb Messerschmidt, Gmelin, and Steller. Unfortunately for Mounsey, when Catherine overthrew her husband, she also removed Mounsey from the Medical College in her general dismissal of all of Peter's ministers, even if the official reason was Mounsey's “ill health.”³⁶

During his time in Russia, Mounsey was an active correspondent, publishing several notes in the Royal Society's Philosophical Transactions and submitting suggestions to the new Royal Society for Arts, Manufactures, and Commerce.³⁷ In Britain, his contributions to natural history, both from his involvement in exporting rhubarb from Russia and attempted investigation of the source of castor, were known.³⁸ In terms of his Russian career, however, his medical expertise may have been more significant. In 1748, for example, he published case notes on the treatment of a woman “from Whom a Foetus Was Extracted.” It involved an unnamed “Soldier's Wife” in Finland in 1742. Her symptoms began in September 1741, when “she felt a Pain beneath the Navel, with a Swelling and Redness, which in about three Weeks appear’d like a small Boil. This she pierced with an Awl, and a yellow-colour’d Water ran from it without any Smell, and continued so to do for near three Weeks more, when it discharged a purulent stinking Matter.” The following June, eight months after these initial symptoms, “two small Bones came out, which were given to the Surgeon that visited her; who only applied a Piece of Plaister, persuading her that a Cure was impossible.”³⁹

In October 1742, “this unhappy Woman applied to Dr. Mounsey, who, after a careful Examination, undertook to deliver her.” The initial surgery that followed was unsuccessful, because “she being unruly, and the Operation not going on to the Doctor's Liking,” the procedure was halted, “only some loose Bones were extracted.” The following day, the Army surgeon and Mounsey continued, with a larger incision making “a large Opening” from which a “fetus” was extracted, comprised of “matter” that “had a very nauseous Smell, and continued of Membranes, Fat, and corrupted Flesh.” At that point, the operation “having been long, and the Woman fainting away, the Wound was dressed, without attempting to extract more at that time. In the Evening she was taken with Vomitings; but by proper internal Medicines, and Flannel Stoups were wrung out of hot Wine, applied over the whole Belly, and often renew’d, she found Ease, and grew better.” The next day, a third surgery followed, removing “the Bones of the Trunk, and most of the other large ones, with their Ligaments and rotten Flesh, were taken out. The Matter discharged for several Days was of a dark-brown Colour, occasion’d by Blood issuing from the dilated Pores of the internal Surface of the Sack.” Mounsey's conclusion was that the “sack” was one of the fallopian tubes. Remarkably, the “Wound was cured in about six Weeks, and the Woman deliver’d from a long State of Misery grew fat and lusty, and now enjoys good Health.”⁴⁰

There was no question to Mounsey that the woman's earlier illness, in September 1741, was directly linked to the surgeries that followed in October 1742. The idea of this woman surviving an ectopic pregnancy for thirteenth months seemed plausible to him. Equally remarkable, “the Woman came by Sea to Stockholm above a Year after this Cure [the three surgeries], and was presented to the Academy in good Health; and the Doctor [Mounsey] believes she is still alive and well.”⁴¹ As evidence of the accuracy of this account, Mounsey and Sir George Baker included a citation to the original publication of the incident in the Acts of the Swedish Royal Academy, which was the location of the final examination of this astonishing patient.

Very little of this case study could be truthful according to modern medicine. Surviving an ectopic pregnancy for four months would be remarkable now, much less then. Surviving three surgical procedures in short succession, without anesthesia, in the 1740s would be implausible, if not impossible. Because Mounsey was involved in the case, it seems reasonable to assume the details he observed were accurate, but he was not involved in the surgeries, just the diagnosis and recovery, nor was he involved in the original examination the previous year. It is likely this case is a collection of disconnected incidents, or even manufactured ones. Considering the timing of this publication in connection with addition of obstetrics to the Russian medical curriculum in the 1750s, however, reveals more about the medical establishment's intentions than it does about the accuracy of the details. The Russian Academy not only was focusing on a curricular change but also had employed leading specialists in the field. Mounsey's rise through the ranks to become head of the College of Medicine confirmed this commitment.

Catherine's dismissal of Mounsey did not change the pace of medical reform. Her government turned to a different British man, Daniel Dumaresq, the former chaplain of the Russia Company in St. Petersburg, to supervise the design and implementation of the new curriculum in 1765.⁴² Dumaresq had been involved with Catherine's son's education, and he had gained some attention for his scientific work by publishing a summary of Stepan Krasheninnikov's findings on the Kamchatka Expedition in Philosophical Transactions in 1759.⁴³ Catherine and Dumaresq's medical education reform was followed by new guidelines on best practices for childbirth in 1766, maintaining the state's commitment to improving the birth rate.⁴⁴ Two years later, further changes were promulgated for the medical curriculum at the hospital schools. The government required the College of Medicine to hire translators to support importing more medical treatises from Europe. It also confirmed the continuing importance of maintaining the anatomy theaters and botanical gardens attached to the hospital schools, leaving the preexisting curriculum intact.⁴⁵ These changes led to a dramatic transformation of Russia's medical knowledge. In the historian S. M. Grombakh's study of Russia's medical literature in the eighteenth century, he uncovered only seven printed medical texts in Russian before 1760s. Thirty-four texts were published in the next decade alone, and this number would only increase for the remainder of the century.⁴⁶ Foreign specialists had always been part of Russia's medical establishment at the state level, but Catherine's government focused on disseminating their knowledge to Russia's medical corps in Russian, theoretically making this material more accessible than ever before.

Montesquieu critiqued Russia's government as a by-product of a cold climate, and Chappe d’Auteroche followed with a scathing indictment of Russia's manifold failures as an imperial power in Siberia. Both men wrote, however, during a period when the Russian government was invested in improving its public health. More of a surprise may be the equally critical assessments by the British, despite the prominent role British physicians occupied in Russia, including several archiaters of the College of Medicine. After Mounsey was removed from office, he was no less judgmental than his fellow diplomats had been: “The State of Learning in this country is scarce yet out of the cradle however knowledge is become justly universal but it is mostly Superficial. There have been many things translated into Russ within these few years But authors in the original Russ are none considerable besides some pieces of Poetry which are said to be very good. The Genius of the Nation is quick and apt to learn, But they make more progress in the Beaux Arts than in Abstract Learning, and it will be many years before they make any figure that near.”⁴⁷ The Academy of Sciences sponsored expeditions that searched for methods to mitigate the damage of scurvy and syphilis; new specialists were hired and the medical curriculum was updated to improve the birth rate of the empire. Public health had become an imperial concern, even if Russia's critics had not noticed.

Solving Smallpox

Smallpox was the major pandemic of the eighteenth century. Mortality rates globally reached new highs. Historians of disease have speculated that it was during the century that the primary variant of smallpox circulating globally became variola major rather than variola minor, as a way to explain the mortality spike, but this theory remains unproven. Before the eighteenth century, inoculating against smallpox may have been unknown in Europe, but several methods had been adopted globally. News of a potential inoculation method reached Britain in 1714, when Emanuel Timonius, an Italian-educated physician in practice in Constantinople, reported his knowledge to a college in the Royal Society of London; this method was published in English in Philosophical Transactions shortly thereafter. According to Timonius, “The Circassians, Georgians, and other Asiaticks, have introduc’d this practice of procuring the Small-Pox by a sort of Inoculation.” His recommendation was to find a “some Boy, or young Lad, of a sound healthy Temperament, that is seized with the common Small-Pox,” then “press out the Matter coming from them,” and then inject that pus into “several little Wounds with a Needle.”⁴⁸ Following further endorsements from other physicians, a domestic trial was begun and shortly thereafter the royal family would be inoculated. The general public in Britain, however, did not immediately seek the treatment, though domestic clinics continued to operate.⁴⁹

Skeptics of the procedure had some justification. In theory, patients were to be inoculated with the pox from a mild case (or “common” to Timonius). In the eighteenth century, it was left to the doctor's discretion to identify mild symptoms. Now, we might classify these types as variola major and variola minor, but the two forms had not been identified yet. Because major had a mortality rate of 30 percent and minor a mortality rate of only 1 percent, the risks for using variola major were significant. Furthermore, the pox used for the variolation procedure needed to be live rather than dried, and so a patient with active pox needed to be used as the source for treatment. The solution for gathering viable pox was to identify patients in the midst of an ongoing smallpox outbreak, harvest the pox, and inoculate their uninfected neighbors, because the pox could not be stored for future use. The long-term solution was to infect, intentionally, patients to have a ready supply on hand. The solution for an ample supply of previously uninfected patients adopted by British practitioners was to infect orphans in pairs in case one died from the procedure. An orphan's inability to object to being the subject of a dangerous medical treatment made them appealing incubators for the medical establishment.⁵⁰

Even after reaching the highest level of Europe's nobility, other elites continued to resist inoculation. This resistance occurred despite the clear and present danger of a smallpox outbreak. Tsar Peter II of Russia died from the disease on his wedding day at the age of fourteen in 1730, leading to the succession crisis that would bring Anna Ivanovna to the throne. The British consul's wife, Jane Ward, suggested Peter's infection began with an unfortunate cold: “As soon as they got into the room, the emperor complained of the head-ach; this was at first taken to proceed from the cold, but on repeated complaints, his physician was called; … The next day the small pox appeared on the emperor, and on the nineteenth, the day appointed for his marriage, about three in the morning, he died.”⁵¹ Even in Britain, however, inoculation to prevent smallpox made progress with the broader public only in the 1740s, too late for young Peter II.⁵²

By the middle of the century, a British physician, Daniel Sutton, had developed a new method of variolating that he believed was less risky than the initial version that had been practiced.⁵³ Sutton's method involved extensive preparation of the patients and up to two weeks of treatment after inoculation. It began with a “Preparative Powder” composed of calomel (mercury chloride), magnesium carbonate, and cinnabar (mercury sulfite) administered in the evening, followed by salts and water to induce stools the following morning. After five days of this treatment, the patient was prepared for inoculation. As he described the procedure, “hold the launcet, with the flat side upwards, between your forefinger and thumb, just moisten the tip with the [variolous] matter, and then make two small punctures in the arm, about two inches a part, wipe the launcet on the punctures, and it is done; if the blood starts the puncture is deep enough.” Following the procedure, patients were given a “Repellent Pill,” made of Kermes minerals (a mixture of antimony trioxide and antimony trisulfide), powdered Aloe succotrina, and camphire (henna), mixed with wine. On alternating nights until the rash and symptoms had passed completely, the patient would also take “grey powder,” which was the mercury-based preparative powder without cinnabar. Sutton's emphasis in his directions was that the proper powders needed to be administered, but recovery would be supported if the patients were not allowed any butter or meat until “the twelfth or thirteenth day after Inoculation,” but only could have “toast and water” before that date. He also was concerned that patients should not be allowed to “sit hot by the fire especially during their Sickening, for it will increase both their symptoms and the number of Pustules.” In fact, “Every Person should walk out in the air often every day”; and, if necessary, they should be taken outside even if “they let their Heads be ever so bad.”⁵⁴ Sutton's adjusted his treatment to be able to inoculate children as young as six months, and accounted for differences in “strong” and “delicate” constitutions, making it potentially viable for everyone.

Within only a few years, other British physicians began simplifying Sutton's method, primarily cutting costs by reducing the number of expensive medicines. In 1766, Sir George Baker, then the royal physician, described the Suttonian Method of variolation only requiring cold, fresh air. According to Baker, neither the expensive chemical preparations nor the adjustment to the diet was necessary, and he found no evidence of a distinction between an incision and a puncture.⁵⁵ The following year, Dr. Thomas Dimsdale published The Present Method for Inoculating the Small-Pox, presenting himself as the expert of this new method, advocating for Sutton's procedure but also reducing its cost, though not as radically as Baker. Drug preparations would be given less frequently, and young children and those with delicate constitutions should not be inoculated.⁵⁶ By removing those most likely to suffer from the procedure, Dimsdale's revised method produced fewer deaths than Sutton's original clinic.

Considering the historical ties between Russia and Britain, and between the Academy of Sciences and the Royal Society of London, the Russian Empire had multiple opportunities to understand the benefits of variolation as a therapy and a public campaign to inoculate the population. The Second Kamchatka Expedition observed smallpox across the empire, including its devasting consequences for the Indigenous populations of Siberia and Kamchatka. Those consequences were exploited by Chappe d’Auteroche in his condemnation of Russian imperial practices. In 1762 when Chappe d’Auteroche traveled to Tobol’sk, the Russian government had yet to adopt a solution to the smallpox pandemic; by the time he published his critique in 1768, however, Catherine the Great's government had embarked on an ambitious plan to inoculate the public. Meanwhile, the Parlement of Paris had banned inoculation in 1763. It was in fact the French government, rather than Russia's government, that was risking the public's health with its inaction.⁵⁷

With all the changes to medical practice that had begun in the 1750s and continued during the early years of Catherine's reign in the 1760s, the decision to adopt public inoculation against smallpox should not be a surprise.⁵⁸ There was both a lengthy history of the danger of the disease in Russia as well as an immediate threat to the court. Countess Anna Petrovna Sheremeteva, Count Panin's fiancé, fell “very dangerously ill” just before their wedding in 1768. Panin was forced to depart from the house they shared for fear of potentially exposing Catherine.⁵⁹ Sheremeteva died within two weeks of her diagnosis. The British ambassador would describe her as “a young Lady of uncommon merit, beautiful, and immensely rich.”⁶⁰ Catherine had personally intervened to arrange for Sheremeteva's divorce from her first husband to allow her marriage to Panin. Dimsdale would later confirm that Sheremeteva's death and Catherine's potential exposure inspired Catherine's decision to hire an inoculator that year. As Dimsdale detailed, once it was known that “neither rank nor fortune afforded any security against the ravages of this dreadful disease; and the whole court, sensible of the danger to which the Empress and the Grand Duke were exposed, were filled with extreme solicitude for those lives upon which the safety and happiness of the empire so essentially depended.”⁶¹

The Russian government did not consider hiring the inventor of the new method, Sutton, but rather the English physician who promoted himself as the expert in the procedure, Dimsdale. Dimsdale was not Scottish as had been the overwhelming majority of British physicians at work Russia, nor was he born or educated in Germany as was the majority of the medical establishment. His hiring broke all the established networks that had placed specialists in Russia. It is likely that his publishing record, rather than his connections to men already working in Russia, was the key. We must consider the possibility that part of the appeal of Dimsdale in Russia was an expectation that he would publicize the government's commitment to variolation. Given that Dismdale published a series of tracts explaining his success in Russian in St. Petersburg and in English in London, he did exactly that. Dimsdale's recorded successes, however, were based on avoiding general inoculation to treat only the few who were the most likely to recover quickly. Dimsdale's impact on the health of the general public may have been nominal at the time but was significant for the health of the court.

According to Dimsdale's later account, Catherine desired a specialist trained in the Suttonian Method to inoculate herself and the royal family. Dimsdale was proud that the Russian ambassador to Britain, Aleksei Semenovich Musin-Pushkin, came to hire him personally at his clinic in Britain in 1768. If Catherine did desire a Suttonian specialist, few options were available, as the therapy was brand new and not widely used outside of Sutton's clinic at the time. Dimsdale's narrative presented his choice to enter Russian service as an opportunity to benefit humanity, and not for “lucrative motives,” but rather he acted “entirely to the gracious pleasure of her Imperial Majesty.” He departed on July 28, 1768, taking his son, who was currently in medical school in Edinburgh, to act as his assistant.⁶²

In Dimsdale's recollection of his time in Russia, he acted professionally and quickly to prepare Catherine and her court for the treatment. Dimsdale suggested first “inoculating some of her [Catherine's] own sex, and age, and as near as could be of similar habit” to observe the consequences of inoculation in a different climate than England's, but “the Empress replied, ‘that if the practice had been novel, or the least doubt of the general success had remained, that precaution might be necessary’; but as she was well satisfied in both particulars, there would be no occasion for delay on any account.”⁶³ Despite Catherine's confidence, Dimsdale was more cautious in the application of his methods and set up a short clinical trial to adjust to the new conditions.

The trial was held at the house of the former head of the Russia Company, Baron Wolff, transformed into Russia's first smallpox clinic, which Catherine purchased for this purpose.⁶⁴ “Dr. Schulenius, a physician of Livonia, who had successfully inoculated many persons in that province, in a method similar to that which was formerly practiced in England, was engaged to live there, and superintend the patients; as also Dr. Strenge to act as his colleague in that employment.”⁶⁵ According to a later account, Schulenius began inoculating in Dorpat “in the year 1756, and practised it with so much success in the country round him, that within eight years he had inoculated 1023 children, of whom only one died.”⁶⁶ Despite Schulenius's experience and successes, the new clinic implemented the Suttonian Method with punctures rather than incisions. Schulenius was left to run the clinic, while Dimsdale stayed at the court. Dimsdale's son, only a medical student, remained at the clinic to supervise the procedures and update his father on its progress. The staff began inoculating with

two young gentlemen of the cadet's corps, … whose names were Basoff and Swieten, about the age of fourteen years (who were supposed not to have had the small pox) were accordingly inoculated. I say supposed, because, however strange it may appear, at that time the nature and symptoms of the disease were so little known and attended to, there were few who could be certain whether they ever had had this disease or not. The general method was to search for marks, and if none were found, it was concluded the party had not had the disease.

Both cadets recovered from the disease within a week, which led Dimsdale to conclude the first experiment was perfect. Consent, however, was not a concern of the physicians. These two cadets were assigned to the inoculation by the court. Dimsdale was later surprised to discover that, in recovery, the cadets “considered themselves as victims devoted to a dangerous experiment,” which Dimsdale blamed on a fever “which might probably increase the patient's apprehensions.”⁶⁷

Dimsdale's subsequent actions, however, confirm that his focus was on preparing Catherine and her court for a safe inoculation, not on the general well-being of his other patients. The two cadets were followed by four more, “and a young maid servant of our family,” who also lacked the opportunity to object to the treatment. All were chosen “as proper subjects for inoculation, and the natural small-pox, in a suitable state for the purpose, was discovered in the suburbs of the city.” In the suburbs, a court surgeon had found a small child, who “was rather full of small-pox; the kind was favourable and distinct, and near the time of maturation,” but he was being kept in a house that was too hot, leaving him “gasping for breath.” To Dimsdale, this was proof of Russia's “improper manner of treating the disease, and the prejudices of the populace,” as the Suttonian Method required patients to be kept in a space with cool air and good ventilation.⁶⁸

The heat, however, was not Dimsdale's only objection to this treatment. When Dimsdale approached the child with a needle “to take the matter for inoculation, a woman, whom I was soon informed was the mother of child, threw herself on her knees at my feet, with her forehead on the ground, and her arms over her head (the eastern manner of prostration, which is still retained in Russia) in this posture she made a plaintive cry, in a language I did not understand.” The woman, apparently, was under the impression gathering material for inoculation would lead to the death of her son. Although Dimsdale was “shocked at the thought of being considered a murderer,” he informed the surgeon to assure the woman that no harm would come to her son, and then he proceeded to inoculate all of five of his subjects.⁶⁹

Dimsdale's second experiment was not a success. The five patients all “appeared to be infected by the operation,” but none developed the illness after a week.⁷⁰ His hypothesis was that all must have been exposed to smallpox earlier in their lives, but unfortunately had failed to show any telltale marks to demonstrate their previous infection. As he later complained to the British ambassador, his “first patients had so little eruption that tho’ he was convinced many of them really had the small pox, it was difficult to propagate the Distemper from them.”⁷¹ Dimsdale rejected an argument that suggested Russians constant use of the bathhouse led to “increased flow of perspiration” that might have provided some protection.⁷² The Suttonian Method relied on cold, fresh air, rather than heat, making the bania particularly suspect. To prove his theory, Dimsdale ordered his staff to inoculate each of the five subjects a second time, “in the old and original manner, still practised by Dr. Schulenius, by a long incision, in which lint moistened with matter was inserted, and the wound covered with a plaister. I recommended likewise, that the patients should frequent the rooms of those who were under the natural small-pox, even of the worst sort; that they should touch the sick, and use every means that might expose them to receive the disease.”⁷³ Dimsdale's disregard for his patients’ health is not surprising in an eighteenth-century context. Neither the cadets, who belonged to state service, nor his own maid could have opted out of the treatment. Dimsdale's only concern was Catherine and her court; he took the necessary steps to treat his royal patron, not her subjects.

Despite the failure of Dimsdale's second trial, Catherine instructed him to move forward with her treatment. Therefore, he “selected and inoculated three children of good constitutions, to be ready, as near as could be computed, at the time agreed on.” These subjects were cared for in the makeshift hospital, and when the infection reached the proper stage, one of the children was taken while asleep to the palace, where “the inoculation was soon performed, after which my son returned back to Wolf House, with the child, and intimated to the family there (who were anxious to know what had been done), that I had inoculated the child of a nobleman.”⁷⁴ It was perhaps not necessary for the child's parents to know that she had been used to inoculate Catherine the Great, but it is notable that they also were not informed when their daughter was taken from the hospital. Dimsdale's inoculation was a medical success but was facilitated by a kidnapping. Although Dimsdale was “sworn to secrecy” about Catherine's procedure, regular updates circulated around the court.⁷⁵ Following her treatment, Catherine “who has only had the slightest Indisposition, and has never been confined to Her Apartment since the Operation, had … a very favorable Eruption of the small Pox, very few in Number, and of a Quality entirely to Doctor Dimsdales Satisfaction.”⁷⁶

From a modern perspective, his methods are questionable at best, if not criminal, but without doubt that Catherine the Great considered her inoculation a success. Once she recovered, she described her decision to be inoculated in a letter to Voltaire, having “thought the best thing for to do would be for [her] to set a personal example which might be of use to people.” Following Dimsdale's procedure, she did “not have a moment's illness, and have been receiving people every day.” Confidently she proclaimed, “everyone wants to be inoculated; a bishop is going to have it done, and more people have been inoculated here in one month than in eight at Vienna.”⁷⁷ Voltaire had been a long-term advocate for inoculation, having included an essay on the topic in his Letters concerning the English Nation (1733).⁷⁸ Catherine could hardly have chosen a better audience for her first report on the success of her procedure.

More information was made publicly available in Russia the following year. Surprisingly, the first printed text in Russian on inoculation was a description of the “German” method that had been set aside by Dimsdale's new version.⁷⁹ This first text, however, was shortly followed by an official publication by the Senate that detailed Dimsdale's “brief and clear instructions” on his new method of extracting pus from live pox and injecting the material into the arm as the correct method.⁸⁰ By the end of 1770, only two years after Catherine's treatment, two more pamphlets written by Dimsdale and translated into Russian were published by the Academy of Sciences, leaving little debate about which method of inoculation would be deployed across the empire.⁸¹

Considering the sheer size of the Russian Empire, it could not be a quick achievement to inoculate the population. Dimsdale was a strong advocate for expanding the inoculation program across the empire as soon as possible, but he expected the government to intervene in each village individually, without considering the logistics of that plan. Although he was confident noble families would easily undertake their inoculations at home, “the poor cannot enjoy those advantages. Humanity, however, and the interest of the state equally demand, that all possible attention should be bestowed for their assistance and preservation.” Dimsdale recommended the Russian Empire follow a “certain method” he had employed in Britain. The government should prepare a list of every person in each village, by name, sex, and age, and mark whether or not they had recovered from smallpox previously. With that list, one physician could enter the village, variolate everyone who had yet to be exposed “on the same day: and, if this be performed in a proper manner, they might be all duly visited, and proper medicines administered at a moderate expence, and the whole be over in about three weeks: after which, that village would have nothing to apprehend from the small-pox soon after its birth, or that inoculation should be performed in every town or village once in five or six years.”⁸²

It was not that his plan was not sensible, but it required information the Russian government simply did not collect on a systematic basis. The first general census of the Russian Empire would not occur until the end of the nineteenth century. Multiple district or regional tax assessments could have included demographic data as early as the seventeenth century, but that process would have needed to be overhauled to gather the correct information, keep it up to date, and effectively centralize and collate the data. Then a sufficient number of medical practitioners would need to be employed to cover Russia's vast expanse, and, somehow, the new administrative staff, medical practitioners, and necessary supplies would need to be financed. If that was not challenge enough, smallpox would need to be kept live to allow variolation. Was Dimsdale's plan to forcibly seize more children? Would they take serfs? Recruits from the army? None of these necessary decisions were included in his plan. To be fair, no country in the world had managed this type of system on a national scale by the 1770s. It may be inspiring that Dimsdale assumed Russia could be the first.

The state persisted in the expansion of inoculation across Russia in the 1770s, but hardly on the scale Dimsdale expected. A journal published a discussion of the inoculation process in 1772, disseminating knowledge to the literate public, to support the expansion of the treatment.⁸³ The first clinic outside of St. Petersburg was established in Moscow, where one of its hospitals established a specialized wing for inoculating children. English minister and traveler William Coxe visited the city in the fall of 1778 and was impressed that the public hospital in the city had a facility “capable of containing 200 children” during treatment.⁸⁴ Samuel Bentham, an Englishman hired to inspect the mines in Siberia by the College of Manufacturing, observed physicians inoculating the Indigenous populations of Siberia during his tour of the region in 1781. When he traveled to Kiakhta on the Chinese border, he noted a physician from Irkutsk inoculating the community of Tatars near Bratsk, demonstrating that the instruction issued in the previous decade was still being following.⁸⁵ By the time that Catherine's government issued its general directive for the inoculation of the public in October 1787, which was upheld and reissued by the Senate the following spring, a significant, empirewide investment had been made in making the procedure available to the general public, not only for the Russians but also for the other imperial populations.⁸⁶ This is not intended to provide an overly optimistic view of smallpox treatment in Russia. While St. Petersburg, Moscow, Kyiv, Kazan’, and Irkutsk had inoculation clinics established, the scale of the empire left considerable space between these treatment centers.⁸⁷

The establishment of these few clinics across the empire was still a notable achievement, as Russia acted in advance of most European nations in terms of its commitment to smallpox inoculation. Russia's success was a surprise, even to its court. As the British ambassador wrote, “The ancient Russ has a great Dislike to Inoculation, as Mr. Panin espoused it, the Question might have become serious, had not the firmness and address of the Empress and her Minister got the better of all opposition.”⁸⁸ Catherine's commitment to the process, however, did not mean that everyone shared its confidence in the process. Variolation, after all, was still a controversial treatment.

Given the remarkable freedom Dimsdale was given to run his smallpox trials, establish variolation clinics, and seize children from their homes to produce the pox, it might be expected that the value of inoculation was well understood. The devastation done by the disease in the Russian Empire had been a key topic for decades, raised by both Russia's specialists and foreign critics. Dimsdale, although hired to guide the solution, acknowledged that it was “impossible for me to ascertain with any degree of certainty, the precise number of persons who die annually of the small-pox in Russia.” He instead projected a mortality rate from his knowledge of London's rate, “which enjoyed many advantages” that Russia lacked; therefore, Russia's rate must be worse. His prediction that “two million souls” died from smallpox each year in Russia seems impossibly high. His concern, however, was not the total loss of life, but rather “how much riches and strength of states depend upon the number of inhabitants. But perhaps there is not any country in which the certainty of this position is more indisputable than in Russia; for not only the strength of the empire, but the riches of every individual also, must be in proportion to the degree of population.” Therefore, any loss of life from smallpox “must greatly retard the increase of the human species.”⁸⁹

After successfully treating the court, Catherine rewarded Dimsdale with the title of baron the following year, given “in justice to the rare Merit and skill of Thomas Dimsdale English gentleman & Doctor of Physic, whose humanity, Virtue & laudable Concern for the good of mankind in General, induced him long since to apply all his Thoughts, & Faculties towards improving and perfecting the Inoculation of the small Pox as they only Rational Preservation of the human Species from the destructive consequences of that mortal Disease.”⁹⁰ According to the patent of his baronage, Dimsdale not only inoculated the court but also “destroy’d at the same time that baleful Hydra Prejudice & the dreadful apprehensions of this hitherto Fatal Disease.” In recognition of his accomplishments, Catherine the Great's government awarded him with a new title, the rank of counsellor of state, and a pension for life of five hundred pounds per year.⁹¹ Smallpox inoculation was personally profitable for Dimsdale.

In his published Tracts on Inoculation, Dimsdale argued that all attempts to preserve human life had value because the people were the wealth of the state. It was not an argument he made alone, as it was a recurring idea of the Enlightened era. French critics attacked Russia for its extreme climate and its propensity for autocracy and for its responsibility for introducing venereal disease and smallpox to Siberia and the North Pacific, where they threatened to eliminate the population. The Russian government, however, was making steady progress addressing its health woes following the evidence gathered on the Second Kamchatka Expedition. More scientific and medical information was imported, the medical curriculum was reformed, and new specialists were hired. By the 1750s if not earlier, the state had committed to increasing the population. Dimsdale's very public career was the cap on two decades of progress, not an uncertain first step.