The sesquicentennial of the American Civil War has generated a good deal of reflection on the impact of the war on American society at large, from the powers held by its federal government to how Americans conceive of and manage death and disability themselves. Margaret Humphreys was well ahead of this curve, first evaluating the social factors at play in the differential health of black versus white soldiers in the Civil War in her 2008 book, Intensely Human: The Health of the Black Soldier in the American Civil War. In Marrow of Tragedy, Humphreys not only relates how both north and south responded to ‘the health crisis of the Civil War’, but realigns the very historiography of American medicine by demonstrating the unexpected impact of the war on the delivery of health care in America.

The Civil War indeed represented a health crisis, with neither side initially prepared for the war-related injuries and disease that would ultimately leave more than a million Americans dead. In response, both north and south created a network of hospitals, ranging from truly ad hoc field hospitals all the way to enormous general hospitals built in large cities behind battle lines. While both sides drew from the lessons of Florence Nightingale and the Crimean War, building such general hospitals in accordance with the pavilion model and maximising ventilation, the north (epitomised by Philadelphia’s Satterlee Hospital, with its own library and entertainment for its convalescing patients) was able to dedicate far more resources – food, medicine, nurses, even guards to prevent desertion – than could their southern counterparts (epitomised by Chimborazo Hospital in Richmond).

Broader disparities in both prevention and care stemmed not only from the differential organisation and economics of northern versus southern society, but from the efforts in the north of the United States Sanitary Commission (USSC), organised to bring the health-promoting components of home – food (especially antiscorbutics), supplies, the very insistence on not defecating where one ate – to camp. The USSC was not without its critics, especially those opposed to its centralised paternalism and maternalism. And the USSC’s comparative assessments of southern versus northern prisoner-of-war camps (highlighting the horrors of those of the south, while publicly downplaying the privations encountered in the north) reveal its own capacity to subjugate its ideals to the pragmatic needs of both the north’s and its own survival. But the USSC’s efforts to bring the cleanliness and order of home to camp was emblematic of more fundamental changes in how medicine and public health could take care of all citizens moving forward.

One such fundamental change, as Humphreys reveals in wonderfully nuanced fashion, was in the feminisation, as it were, of orthodox medicine. The Civil War certainly made nursing a respectable activity (much as it made the hospital a respectable place to receive care for middle-class and upper-class patients), setting the stage for the professionalisation of nursing that would follow in subsequent decades. It provided some (albeit, limited) opportunities for women physicians to practise directly, and may have provided an inspiration for many others serving in the war as caregivers to go on to become physicians (a possibility Humphreys encourages others to pursue). Still more fundamentally, though, the efforts of the USSC and others to instil the importance of hygiene and of the support of the patient – alongside the heroic efforts of surgeons, whose ligatures would fail to hold in scurvy-ridden patients – contributed to a very feminisation of medicine itself (and of war as well, for that matter).

Perhaps nowhere would such consequences be felt as strongly as with respect to the war’s ultimate impact on surgery and the acceptance of the germ theory. Surgeons and sanitarians alike were forced to confront the practical implications of contemporary debate over the contagiousness of smallpox, yellow fever, cholera and especially gangrene. Disinfectants and antiseptics came into wide use, as did the isolation of seemingly contagious patients. While considerable debate prevailed concerning the nature of such contagion, the widespread exposure of surgeons to such infections, disinfectants and debate alike – mediated by the top-down delivery of instructional manuals and the hierarchical monitoring of care – helped prepare the ground for the uptake of germ theory and antiseptic and then aseptic surgery in the decades to follow.

In unexpected ways, then, the American Civil War unified the medical profession – north and south alike – around common problems and care models, and behind science itself (a theme that historian Shauna Devine has developed further in her own excellent 2014 book, Learning from the Wounded: The Civil War and the Rise of American Medical Science). Margaret Humphreys has written an important and elegantly constructed work; in so doing, she has ensured that historians no longer have the luxury of ignoring the Civil War’s impact on American medicine in the nineteenth century and beyond.