Enslaved Children, Smallpox, and a Confederate Doctor: The Hidden History Behind Early Vaccines

There is a familiar excuse in the history of medicine: it was for the greater good.

It shows up whenever people with power decide that somebody else can absorb the pain. A military emergency. A shortage. A crisis. A population treated as expendable. James Bolton, a Confederate physician during the Civil War, worked inside that logic. The people who paid for it were enslaved children.

This is a story about , war, vaccine scarcity, and what happens when medicine treats human beings as raw material.

Smallpox in a Nation at War

In 1861, the United States was at war with itself during the , and smallpox was making the disaster worse. The disease spread easily in crowded military camps, where sanitation was poor and large numbers of men lived in close quarters. Union and Confederate officials both understood they had a serious problem.

This was not an era of total ignorance. Physicians already knew vaccination worked. , and vaccination campaigns had been underway in Europe and in the northern United States for decades. The Confederate Army even required vaccination for recruits. On paper, at least, there was a plan.

In practice, the Confederacy had a supply problem.

Many Southern physicians had little experience administering the vaccine. More importantly, the Union blockade limited the South’s access to fresh vaccine material. And smallpox vaccination in the nineteenth century depended on that material being available, as there were no laboratories as we have them today, and cold-chain logistics were not yet possible. Doctors needed lymph or crusts taken from a successful vaccination site so they could pass immunity from one body to another. No supply meant no vaccination campaign.

That shortage pushed Confederate physicians toward . You see, children were often preferred as vaccine sources because they were considered less likely than adults to carry infections such as syphilis that could be transmitted along with the vaccine material. A contaminated chain of arm-to-arm vaccination could spread more than protection. It could spread syphilis and other blood-borne diseases. Surgeons knew that. So they looked for children.

And in the Confederacy, there was one population of children that physicians could access with almost no resistance from the law: enslaved children.

Who Was James Bolton?

(1812–1869) was not an obscure crank practicing medicine on the margins. He was a Richmond physician with credentials, status, and influence. He operated a private hospital, , from 1855 to 1866, published a medical book in 1842, edited a medical journal in 1854, and served as a Confederate Army surgeon during the Civil War. He later joined Robert E. Lee’s staff during the retreat from Richmond.

Bolton was part of the medical establishment. His work circulated in professional networks. Other physicians read him, cited him, and learned from him. So when we examine what he did, we are not looking at a bizarre detour in the history of vaccination. We are looking at an example of how mainstream medicine operated when it had access to captive Black bodies and a reason to use them.

What Bolton Did

The vaccination method Bolton used was called . The process was direct and invasive. A physician made small cuts in the skin, inserted material from a previous vaccination, and waited for the recipient to develop the characteristic lesion. When the pustules matured, the physician opened them and collected lymph or removed the resulting crusts for use in the next round of vaccinations.

Bolton traveled through parts of Virginia inoculating enslaved people so their bodies would generate vaccine material. After the infections developed, he retraced his route and harvested what he needed. One surviving medical report states that the trip produced about 800 crusts, "mostly from healthy negro children."

That sentence deserves to be read slowly. Eight hundred crusts. Mostly from healthy children.

The report records efficiency. It records yield. It records success from the physician’s perspective. What it does not record with any seriousness is the experience of the children whose bodies made that success possible.

Bolton was not treating these children as patients in any meaningful sense. He was using them as a supply chain.

What All of This Cost the Children

The children Bolton used did not consent. Their parents did not consent. Enslaved families had no legal authority to refuse a physician backed by the Confederate state and the slave system that sustained it.

The procedure itself was not trivial. It required cuts in the skin, followed by the development of lesions that could later be opened again to collect material. The process could leave permanent scars. It could fail to produce immunity. It could produce serious illness. In some cases, children died.

There was another danger, too. If the original vaccine material came from someone infected with a blood-borne disease such as syphilis, that infection could travel through the vaccination chain. . Their answer was not to abandon the practice. Their answer was to seek “cleaner” sources, which increased the demand for children’s bodies.

Even the surviving documentation tells you what physicians cared about. The reports track whether the vaccine took. They track how much material could be harvested. They track whether soldiers were protected. They do not linger over the pain, recovery, complications, or long-term outcomes of the children who were cut, infected, and used.

That lack of any mention of the children and their health reflects the system’s moral structure.

This Was Not Only a Confederate Story

It would be comforting to file this away as one more horror made possible by slavery in the Confederacy. That would also be incomplete.

There are reports that . These children had escaped slavery, but escape did not place them beyond exploitation. They arrived in overcrowded camps with poor sanitation, limited food, and little meaningful protection. The federal government classified many of them as “,” a bureaucratic category that kept them from being returned to enslavers without granting them the full rights of citizenship.

So yes, slavery shaped Bolton’s work directly. But the broader lesson is harder to ignore. Medicine did not need the full legal machinery of slavery to use vulnerable Black children this way. It needed a steep enough power imbalance, a military emergency, and decision-makers who saw no reason to ask permission.

Why This History So Often Stays in the Background

Historian Jim Downs, in Maladies of Empire, notes that this history is not hidden because nobody wrote it down. It is hidden because the people who wrote the records did not consider the exploitation remarkable. And that is how these stories get buried.

Physicians documented results, not ethics. They wrote about whether vaccine campaigns worked, whether crusts remained viable, and whether outbreaks among soldiers could be contained. The children show up in the archive as inputs. A source. A quantity. A yield. Sometimes not even that. Their names are gone.

When people talk about the history of medicine as a steady march of progress, this is the kind of material that drops out first. Not because it is absent, but because it is inconvenient.

What This Means for Vaccine History

None of this changes the fact that smallpox vaccination was one of the great achievements in medical history. Smallpox killed and disfigured enormous numbers of people. The eventual global eradication of the disease in 1980 remains one of public health’s clearest victories.

But victory stories can be told honestly or dishonestly.

An honest version includes the fact that some of the infrastructure behind early American vaccination campaigns ran through the bodies of enslaved and displaced Black children. It includes the fact that medical innovation and racial exploitation were not separate tracks. They often occupied the same institutions, the same journals, and in some cases the same physicians.

That does not mean vaccines were bad. It means history is not cleaner just because the outcome later saved lives.

If anything, this history should make public health communicators more careful, not less. People are often told to trust medicine because medicine is scientific. Fine. But science is done by human beings, inside institutions, under political conditions, with all the moral failures that implies. Saying that out loud does not weaken the case for vaccination. It strengthens the case for honesty.

The children Bolton used were not volunteers. They were not collaborators in a noble medical project. They were children whom a physician with legal and social power turned into a resource.

And we do not know their names.

References and Additional Readings

1. Downs, J. (2021). Maladies of empire: How colonialism, slavery, and war transformed medicine. Belknap Press of Harvard University Press.
2. Eschner, K. (2017, May 1). Fearing a smallpox epidemic, Civil War troops tried to self-vaccinate. Smithsonian Magazine.
3. Ranscombe P. (2022). Vaccine Voyages: where science meets slavery. The Lancet. Infectious Diseases, 22(7), 956.  
4. Ruggles, R. (2024, August 1). Vaccination and African Americans during the Civil War. National Museum of Civil War Medicine.  
5. Smith, L. E., Driggers, A., & Douthitt, C. L. (2024). History, politics, and variolation vaccination hesitancy in the American South during the American Civil War. Proceedings (Baylor University. Medical Center), 37(2), 357–360.