Why smallpox spread through wartime Richmond

Disease killed more men in the Civil War than combat did. That sentence appears in most textbooks and then nothing is done with it.

Richmond is a good place to do something with it, because the Confederate capital assembled almost every condition that lets a disease move, and then held them together for four years.

What the city became

Richmond in 1860 was a substantial city of around thirty-eight thousand people. Within two years it held vastly more, and nobody knows the real figure because nobody could count it.

Government clerks arrived with the Confederate administration. Soldiers passed through constantly. Wounded men came in from Virginia battlefields by the trainload. Refugees came from occupied areas. Prisoners of war were held in and around the city. Enslaved people were moved in from the countryside to work in the ironworks and the hospitals.

Housing did not expand. Sanitation did not expand. Water supply did not expand.

Why smallpox specifically

Smallpox was preventable in the 1860s. Vaccination had existed since the end of the eighteenth century and it worked.

The problem was supply and quality.

The vaccine of the period was not a stable manufactured product. It was live material, and it had to be kept viable and passed along. The standard practice included arm to arm transfer, taking material from a vaccinated person's pustule and using it on the next person.

That method spreads other things. Erysipelas and syphilis both travelled this way, and surgeons knew it and used the method anyway because the alternative was no vaccination at all.

Wartime scarcity made everything worse. Confederate medical supply was under blockade, and vaccine material was among many things that were short.

So you had a population that was partly vaccinated, partly vaccinated badly, and partly not at all, packed together at a density the city had never experienced.

The crowding that mattered most

Hospitals. Richmond became a hospital city, with Chimborazo on the eastern edge among the largest military hospitals of the war.

Prisons. Libby and Belle Isle held prisoners in conditions that were poor at the start and became very bad indeed.

And the neighbourhoods where the working population and the enslaved population lived, which were densest and had the least access to medical care of any kind.

Where the record is thin

I want to be careful here, and I am going to be more careful than most popular accounts are.

Confederate record keeping deteriorated as the war went on, and a great deal of Richmond's municipal and Confederate records burned in April 1865 when the city was evacuated and fires were set in the warehouse district.

So precise mortality figures for particular outbreaks in particular months frequently do not exist. Where you see a very specific number in a popular article about disease in wartime Richmond, it is worth asking where it came from, because in my experience it often traces back to a secondary source quoting another secondary source.

What we can say confidently is that smallpox was present throughout the war, that it appeared in hospitals and prisons and in the civilian population, that vaccination was attempted and was hampered by supply and by the transfer method, and that the crowding made containment close to impossible.

What is worth taking from it

Epidemic disease is not a natural disaster that happens to a city. It is the product of decisions: where people are housed, how water is handled, whether medical supply is prioritised, who has access to care.

Richmond made those decisions under extreme pressure and with limited means, and the outcome followed from them.

For teaching, the useful exercise is to hand students the list of conditions and ask them to predict what happens, before telling them what did. They get it right, every time, which is rather the point.