Medical challenges and advances in the American Civil War Festschrift Honoring Basil A. Pruitt, Jr., M.D.

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There were two major factors in the mid-19th century that led to the Civil War: the institution of slavery, and a determination that the Union be preserved. These factors were inextricably linked. The bases for conflict had been growing since the American Revolution 80 years earlier. Slavery had been the linchpin for the agrarian society of the South. A major portion of the economy in the slave-holding states was based on agriculture with limited development of industry. In the Northern states agriculture was primarily based on small family farms. Importantly, the Industrial Revolution had transformed the Northern economy into a manufacturing base, primarily surrounding large metropolitan areas. This led to significant population growth in the North compared with the South and also provided a major military advantage by providing a much greater capacity for production of armaments.
A relatively small, vocal abolitionist contingent initially based in the Northeast at the end of the 18th century, gradually spread in degrees across the Northern states. The drumbeat for the abolition of slavery reached a crescendo by the middle of the 19th century. The Southern states became highly resentful of this agitation, which was a threat to their entire society. Slave labor had provided the only way they knew to maintain the economic structure of the large plantation system. However, only 23% of Southerners actually owned slaves. For the Confederacy, it was to largely become “a rich man's war and a poor man's fight.”
John Brown’s violent abolitionist activities in “Bloody Kansas” produced seminal events leading directly to war. Brown and a small group of followers attacked and killed five proslavery people at the Pottawatomie Massacre in 1856. He went on to seize the federal arsenal at Harpers Ferry, Virginia, with the intent of arming slaves and inciting a rebellion. He failed and was killed there. Those activities helped put the country on a direct line to civil war.
Abraham Lincoln took the office of Presidency of the United States in March 1861. He was determined to preserve the Union at all costs. Lincoln did not believe that the Southern states had a right to secede from the Union and he never considered the Confederacy a separate country. He often stated that he wished to restrict the spread of slavery, not to abolish it. However, agitation from both abolitionists and proslavery firebrands had produced a searing climate that would not tolerate Lincoln's attempts at appeasement. As the war progressed, Lincoln’s feelings shifted for several practical reasons, and he determined that the only solution was to abolish slavery in the United States.
At the onset of war in 1861, the geography of North America was such that there were 23 states in the Union; in four Union border states, slavery was legal, including Missouri, Kentucky, Delaware, and Maryland (Fig. 1). Eleven states seceded to form the Confederate States of America. A significant portion of the map that would eventually become part of the United States included a swath of eight territories in the western half of the country. The Civil War was initiated on April 12, 1861, when Confederate forces under the command of General P.G.T. Beauregard attacked Fort Sumter off the Charleston, South Carolina coast. The fort was surrendered 2 days later.
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