The United States Sanitary Commission & Disease Control During the American Civil War

Disease and illness have taken innumerable lives throughout history. Unfortunately, this threat does not dissipate during periods of human conflict. In fact, warfare often exacerbates the causes of disease and promotes the creation of unsanitary conditions for soldiers and civilians alike. In the American Civil War, disease was responsible for approximately 160,000 to 200,000 deaths and 220,000 medical discharges in the United States Army. Records indicate an additional six million non-lethal cases of disease occurring among the Union Army throughout the conflict.¹ To prevent the spread of disease and care for both active duty soldiers and veterans, the Secretary of War established the United States Sanitary Commission (USSC) on June 9, 1861. President Lincoln formally approved this order four days later.² While the activities of the Sanitary Commission have been documented, few analyses of the Commission’s role in the control of infectious disease appear in the historical literature. The USSC’s efforts to keep camps clean, orderly, and free of disease were hampered by the limitations of early nineteenth-century medical knowledge and the ignorance of soldiers and commanders. However, the USSC found ways to overcome these obstacles and contribute to the health and well-being of the Union army.

To understand the limitations of the practices promoted by the USSC, one must first understand the medical knowledge available at the start of the Civil War. The foundation of modern infectious disease control is germ theory. A basic understanding of germ theory, the principle that microorganisms cause infection, is common knowledge in the twenty-first century. However, the seminal works that led to the creation of germ theory, such as the research of Louis Pasteur, Joseph Lister, and Robert Koch, did not become mainstream until the last three decades of the nineteenth-century.³ An examination of contemporary medical literature elucidates the limited medical knowledge of the era. For example, The Medical Student’s Vade Mecum, written in 1847 by Dr. George Mendenhall, a professor of pathology and medicine, provides little to no information about some of the most common infectious diseases. In fact, this book claims that dysentery, one of the most common causes of death among Union soldiers, is caused by “atmospheric vicissitudes.”⁴ The recommended course of treatment includes purgatives and bloodletting, as opposed to the rehydration therapy recommended by modern medicine.⁵ While the more egregious of these practices, such as bloodletting, had fallen out of favor by the Civil War, many commoners and doctors still believed in miasma theory and the benefits of purging.⁶

While the disease control operations conducted by the USSC were not grounded modern scientific best practices, their attempts at keeping soldiers healthy were not entirely futile. In his book, Mosquito Soldiers, historian Andrew Bell states, “medicine in the 1860s was a hodgepodge of ancient shibboleths, folk remedies, and sound scientific practices.”⁷ However, some “ancient shibboleths” did intersect with sound scientific practices. For example, the principal of separating the sick from the healthy has been practiced since antiquity. The USSC engaged in this practice by quarantining diseased soldiers or sending them out of military camps to designated hospitals.⁸ During the 1864 yellow fever outbreak in New Bern, North Carolina, Union and USSC officials transferred healthy soldiers out of the town to prevent them from contracting the disease.⁹ Although such actions were taken based on miasma theory or other flawed medical knowledge, they were likely one of the USSC’s most effective methods of disease control.

In addition to quarantining soldiers once disease outbreaks began, the USSC’s repertoire of disease control techniques included more preventative measures. For example, inspectors were appointed to survey the sanitation and cleanliness of military camps and provide advice on the improvement of hygiene. These inspectors examined a wide array of practices, including camp sewage systems, rations, methods of cooking, the construction of tents, the quality of clothing, and the personal hygiene habits of soldiers.¹⁰ While these inspectors may not have truly understood why keeping sewage away from food and potable water was important, or why thoroughly cooking meat decreased the prevalence of gastrointestinal disease, these practices were certainly helpful. Although keeping a “clean” and “hygienic” camp may seem like common sense to modern peoples, Civil War era medical professionals reported that “precautions for health; preventions for disease; the bodily well-being of the troops…scarcely entered, if entered at all, their [the soldier’s] eager minds.”¹¹ Therefore, the USSC helped reduce the prevalence of disease by encouraging soldiers to engage in basic hygienic practices, despite the lack of scientific medical knowledge available.

While the USSC’s inspectors helped promote health, uneducated or naïve military officials diminished these inspector’s overall effectiveness. Indeed, it is striking how little consideration some military officials gave to the prevalence and impact of disease. In a letter to Major General George McClellan during the 1862 Peninsular Campaign, President Lincoln questions why records indicate that approximately 45,000 men were alive but not with the army or fit for service. Seemingly, despite receiving reports on the issue, the president failed to understand that enteritis and other diseases had racked the army since the beginning of its deployment, leaving tens of thousands of men under quarantine, evacuated, or too sick to fight at any given time.¹²

Unfortunately, the lower ranking officers were not any more informed about the dangers of disease. In the official history of the United States Sanitary Commission, the author states, “…neither the public… nor the officers, who were entrusted with the responsibility of their [the soldier’s] precious lives, seemed to have any adequate conception of the absolute necessity of preventive measures to maintain this buoyant energy of our young men ever fresh and active.”¹³ Furthermore, there is evidence that officers and commanders would attempt to hide disease outbreaks for a variety of reasons, such as avoiding a panic or personal embarrassment. One notable case of disease cover-up occurred during the New Bern yellow fever epidemic. D.W. Hand, the medical director of Union forces in the area, initially failed to acknowledge the outbreak when it was first reported to him. When Dr. Hand finally reported the issue to his superior, General Palmer, the general was initially outraged and sought to further conceal the outbreak.¹⁴ Despite these setbacks, the USSC rushed to control and counter the epidemic. Indeed, one local noted that Dr. Page and Dr. Sitler of the USSC were “superhuman in their endeavors” to control the outbreak.¹⁵

To combat problems with uncooperative officers, the USSC brought its significant political influence to bear. In 1863, the USSC lobbied Lincoln’s administration to replace the aging Director of the Army Medical Bureau with the younger and much more reformist William Hammond. Under Hammond’s watch, USSC inspectors and physicians were more effectively and thoroughly integrated into the day-to-day operations of the Union armies.¹⁶ Additionally, the USSC advocated for the passage of legislation which provided their inspectors and physicians with military rank, thus allowing these individuals to more forcefully advocate for the advancement of sanitary practices.¹⁷

The USSC also worked to gain the trust and respect of military officials in order to make them more amicable toward USSC operations. For this reason, one of the most important selection criteria for a USSC inspector was his personality and social skill. Specifically, a USSC inspector was required to possess “…sufficient tact to perform their duties as agents of an organization till then unknown to Army Regulations, without awakening jealousy of their interference as officious or seemingly intrusive.”¹⁸ Perhaps due to this stringent selection criteria, the USSC’s agents appear to have garnered much goodwill among a majority of the Union army.¹⁹

The effective cooperation between the army and USSC was one of the Commission’s crowning achievements. However, the USSC’s role in ensuring high quality training and treatment was also notable. Not only did the USSC ensure that its own inspectors possessed the relevant qualifications, but it was also involved in providing additional education to army surgeons in the form of “medical monographs.” These monographs, published with titles such as “Report on the Value of Vaccination in Armies” and “Quinine as a Prophylactic against Malarious Disease,” proved to be so popular that many surgeons wrote to the USSC asking for replacements when their original copies were damaged or lost.²⁰ The USSC also worked to ensure that Union physicians received the supplies needed to efficiently carry out medical procedures and keep soldier’s comfortable.²¹ For example, one hospital worker stationed with the Army of the Potomac wrote that the USSC furnished relief chests “…which were carefully provided with a great variety of stores and utensils for hospital use…and which were packed with great ingenuity and skill.”²² These efforts in supplying and educating the physicians of the Union army likely led to improved quality of care for United States troops.

The USSC’s record of ensuring high quality medical training and cordial relations with military officers is more impressive when contrasted with the situation in the Confederacy. According to historian Joseph Glatthaar, Confederate doctors had little ability to regulate sanitation practices in Confederate armies. Throughout the war, the advice of southern medical professionals was largely ignored and the cleanliness of Confederate camps suffered accordingly.²³ Furthermore, Glatthaar catalogues the many complaints levied against the healthcare system and doctors of the Confederacy, arguing that they were generally understaffed, undersupplied, and underprepared.²⁴ To no fault of their own, Confederate officials also lacked experience with public sanitation practices. The north, in contrast, had been dealing with such issues for years in major cities like New York.²⁵ For example, in the early 1840s, several doctors and public health authorities worked to write a report on the sanitary conditions of New York and recommended several changes and improvements. Many of the topics discussed were similar to those targeted by the USSC during the Civil War, such as drainage, sewage, food safety, living conditions, and ventilation.²⁶ Considering these facts, it is no surprise that USSC agents had an advantage over their southern counterparts in terms of knowledge and experience.

Considering the improvements implemented by the USSC, and the knowledge base of its agents, one would expect the morbidity and mortality rates among Union troops to be lower than those of the Confederate forces. However, the data does not necessarily indicate that this was the case. Drawing data from the Medical and Surgical History of the War of the Rebellion, historian Paul Steiner concludes that the death and discharge rates due to disease in the Confederate army were roughly proportional to those of their northern counterparts. Of course, the numbers alone may not convey the full story. It is entirely possible that various confounding variables influenced outcomes. For example, since the Union generally had larger armies in the field than the Confederacy, this may have led to the construction of camps that were more densely packed and thus more prone to disease. Similarly, northern soldiers likely lacked any degree of natural resistance to some diseases found in the warmer and wetter homelands of the Confederacy.²⁷ The USSC may have had impacts that did not manifest in the data, such as decreasing convalescence times by reducing the rate of secondary infections or minimizing the financial costs of medical care by ensuring the efficient use of medical resources.

Turning to contemporary accounts, one can see that the USSC was viewed as fundamentally successful at reducing the prevalence of infectious disease. Since information on Confederate casualties was not available until many years after the war, many contemporaries compared the USSC to the British Sanitary Commission of the Crimean War. While some of the challenges facing these two organizations were quite different, the comparison is logical due to the temporal proximity of the two Commissions. Furthermore, the British Sanitary Commission likely served as the inspiration and founding model for the USSC, although some authors tried to downplay that connection after the conclusion of the war.²⁸ In Katharine Wormeley’s book on the USSC, she concludes that the Commission kept American mortality rates far lower than the rates seen among British forces before the establishment of the British Sanitary Commission. However, she acknowledges that the USSC did not reduce mortality rates to the same levels recorded in Crimea after the British Sanitary Commission was in operation for several years. She attributes this disparity to the harsh climate in the American south, where “…every breath drew in swamp poison, and our men advanced by forced marches through Virginia mire, and camped along the banks of malarious watercourses….”²⁹ Wormeley concludes this section of her book by restating her belief in the efficacy of the USSC’s efforts, especially considering the harsh circumstances mentioned previously.³⁰

Regardless of the USSC’s true effectiveness at reducing mortality and disease prevalence, the Commission was perceived as being an integral and essential part of Union military operations. Indeed, the sheer volume of praise heaped onto the USSC by contemporary soldiers, officers, and politicians is striking. Wormeley’s record of the USSC’s work ends with a compilation of complimentary letters sent to the USSC. Of these, the following quote from an unknown soldier most accurately summarizes the general perception of the USSC: “We soldiers know best what the Commission is. You all see it, but we feel it. I bless the Sanitary Commission every time I see its name posted up — or think of it.”³¹ While such statements are indicative of strong positive feelings toward the USSC, the Commission was engaged in efforts to boost its own image using marketing and propaganda techniques. For example, during the later stages of the war, the USSC published The Soldiers Friend. This book describes itself as containing “…a statement of what their [the soldier’s] friends at home are doing for them through the U.S. Sanitary Commission….”³² Along with portraying the USSC in a very favorable light, this book also includes hymns, devotionals, and other information that soldiers may find useful.³³ Works like this leave one to wonder if the USSC’s greatest impact may have been on the moral and psychological well-being of soldiers, rather than their physical health. Nonetheless, the USSC was highly regarded by Union soldiers and clearly engaged in efforts to preserve and enhance this image.

A general sentiment of trust towards the USSC is further evidenced by the fact that they were trusted with, and sought, the most serious medical cases. Based on letters between a USSC employee and his mother, one can discern that the USSC General Secretary made an agreement with the Army Medical Bureau to ensure that “…the worst cases and the greatest suffering shall be under its [the USSC’s] own eye.”³⁴ This was done by establishing a medical transport system for soldiers seriously injured in the Peninsular Campaign.³⁵

This transport system is just one example of the many other duties and activities of the USSC which require further study and analysis. The USSC benefited the northern war effort by improving the moral of soldiers and by delivering relief chests filled with donated supplies.³⁶ However, in terms of disease control and prevention, the USSC’s record is more mixed. The limited medical knowledge of the time and difficulties with the soldiers and commanders of the Union army hampered the Commission’s efforts. However, the USSC tackled these issues using innovative methods which worked well within the U.S. military apparatus. Despite these measures and the skill of USSC personnel, the organization’s impact on morbidity and mortality rates in the Union Army remains unclear. Quantitative data aside, the USSC’s extremely favorable perception in the eyes of northerners suggests that it did have a positive effect on the Union war effort and was successful in its mission to control infectious disease.

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