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What Killed Stonewall Jackson, and Could Modern Trauma Medicine Have Saved Him?

Friday, May 10, 2013

Thomas Jonathan “Stonewall” Jackson
 Thomas Jonathan “Stonewall” Jackson
 

University of Maryland School of Medicine Trauma Surgeon Considers Death of One of Civil War’s Most Renowned Generals, Struck Down by Friendly Fire in 1863

It has been 150 years to the day since Thomas Jonathan “Stonewall” Jackson died after being struck by friendly fire from his own Confederate troops during the American Civil War. A question still remains for physicians and historians: What type of medical complication killed one of the most influential generals of the Civil War? A surgeon from the renowned University of Maryland R Adams Cowley Shock Trauma Center and a noted historian and Stonewall Jackson biographer will take up the case of the exact cause of Jackson’s death at the 20th annual Historical Clinicopathological Conference, sponsored by the University of Maryland School of Medicine and the Veterans Affairs (VA) Maryland Health Care System. In fact, the surgeon will conclude that modern treatment at a facility such as the Shock Trauma Center at the University of Maryland could indeed have saved the general’s life. The conference, held this year on Friday, May 10 in historic Davidge Hall, is devoted to the modern medical diagnosis of disorders that affected prominent historical figures.

The physician considering Jackson’s medical case is Joseph J. DuBose, M.D., Clinical Assistant Professor of Surgery at the University of Maryland School of Medicine and a noted trauma surgeon at the University of Maryland R Adams Cowley Shock Trauma Center. He brings a unique perspective to General Jackson’s death in action — Dr. DuBose is a veteran of the United States Air Force who achieved the rank of lieutenant commander. He served in Operation Iraqi Freedom in Baghad, Iraq, in 2009; Operation Enduring Freedom in Kandahar, Afghanistan, 2010; and Operation Enduring Freedom in Bagram, Afghanistan, from 2011 to 2012.

Each year at the conference, the medical expert is joined by a historian who summarizes the life and historical impact of the figure in question. This year’s guest speaker is James I. “Bud” Robertson Jr., Ph.D., who retired in 2011 as Alumni Distinguished Professor of History at the Virginia Polytechnic Institute and State University after a 43-year career at the institution. Dr. Robertson taught the largest civil war history class in American higher education at Virginia Tech, averaging 300 students per semester. He has authored more than 20 books including his seminal, 950-page volume “Stonewall Jackson, The Man, the Soldier, the Legend,” that claimed eight national awards. Dr. Robertson also served as executive director of the U.S. Civil War Centennial Commission, working with Presidents Truman, Kennedy, and Johnson in marking the war’s 100th anniversary.

There is no doubt that General Jackson’s death was caused by the three 0.69 caliber bullets that tore through his body when his men mistook him for the enemy and fired upon him during the Battle of Chancellorsville in Virginia in May 1863. He died seven days later on May 10. Medical experts and historians differ on which complication eventually killed him. Was it an infection? Pneumonia? Dr. DuBose is considering the case based upon his own knowledge of trauma medicine as well as historical documents such as the published report of Hunter Holmes McGuire, M.D., General Jackson’s personal physician.

General Jackson was a legendary military leader, fighting alongside renowned Confederate General Robert E. Lee. He was known for steadfastness and aggression in battle, wishing to destroy his enemy rather than simply disable, according to Dr. Robertson. “His soldiers adored him, and told countless stories about ‘Old Jack,’ even though he was a tight-lipped, sternly disciplined eccentric,” Dr. Robertson says. “Fellow generals were in awe of him because his silence concealed a fiery combativeness smoldering deep inside. Indeed, it was the silence, and the accompanying secrecy of his movements, that led to mortal wounds from musket fire by his own soldiers.”

It was April 1863 when, in the midst of battle, General Lee sent General Jackson and his troops on a secret 12-mile march around the Union forces to attack from an unexpected vantage point, according to Dr. Robertson. On May 2, General Jackson and his troops attacked and drove back the Union troops three miles. After dark, the general and his aides rode back toward their Confederate camp. The soldiers mistook the group for Union troops and fired upon them.

General Jackson was struck three times and brutally wounded. It took two hours to transport him to the field hospital, and his stretcher was dropped twice on the way. Dr. McGuire, his personal physician, amputated his badly wounded left arm. General Lee, concerned for his safety, ordered General Jackson moved further to the rear to recover. General Jackson endured a difficult wagon ride 27 miles to the railhead at Guiney Station. There, several prominent Richmond physicians and Dr. McGuire agreed that the general suffered from fatal pneumonia. He died on May 10, a Sunday afternoon, after saying the famous final words, “Let us cross over the river and rest under the shade of the trees.”

Three years passed until Dr. McGuire published his account of General Jackson’s injury and death, and by then his notes had been captured by Union forces and lost. Dr. DuBose finds much to question about the doctor’s account. Though Dr. McGuire diagnosed pneumonia of the right lung, he made no mention of fever or even the details of his lung exam. He hypothesized that contusion of the lung and hemothorax — blood in the lung cavity — contributed to the death. Some historians agree with his diagnosis, but Dr. DuBose finds other options to consider. He rules out several possibilities that other historians have considered, and settles on pulmonary embolism and pneumonia — Dr. McGuire’s diagnosis — as the likely culprits.

Pulmonary embolism, a blockage in the major blood vessel or artery in the lung, still occurs today in about 5.7 percent of combat casualties in Iraq and Afghanistan, Dr. Dubose notes. It is even more common among those who have had amputations, as General Jackson did. However, several key symptoms of pulmonary embolism are missing from reports of General Jackson’s death, according to Dr. DuBose. Dr. McGuire did not report that General Jackson coughed up any blood, a condition called hemoptysis. He also does not note any change in his pulse, acute shortness of breath or decreased mental ability caused by the kind of low blood pressure, or hypotension, that a large embolism would cause.

It was likely pneumonia that killed the general, and modern medicine could have saved his life, Dr. DuBose concludes. General Jackson was not alone in his diagnosis — pneumonia was the third most fatal disease among Civil War soldiers, and it is estimated that between 15 and 20 percent of Confederate troops developed pneumonia.

“Would Jackson have survived if his injury had occurred on the modern battlefield? It is safe to say that he probably would have,” Dr. DuBose says. Many modern combat casualties suffer from complications similar to General Jackson’s, but doctors can identify them earlier and treat them more effectively now, he explains. Techniques of using tourniquets in the field have improved immensely, preventing hemorrhage and saving lives. Troops now can be evacuated rapidly and smoothly by helicopter, taken quickly to skilled surgeons and sterile operating areas. Medicine has perfected techniques of clearing mucus and blood from the lungs, and mechanical ventilation is available to help patients breathe. Imaging techniques make diagnosis and management of illness much easier and more precise. Modern antibiotics could certainly have helped to cure pneumonia.

“Hunter Holmes McGuire had none of these luxuries of modern medical care at his disposal,” Dr. DuBose says.

General Jackson’s case is the 20th to be considered at the University of Maryland School of Medicine’s annual Historical Clinicopathological Conference. The conference began in 1995, founded by Philip A. Mackowiak, M.D., M.B.A., Professor and Vice Chair of the Department of Medicine at the University of Maryland School of Medicine and Chief of the Medical Care Clinical Center of the VA Maryland Health Care System. The program has examined the lives and deaths of famous figures such as Edgar Allan Poe, Abraham Lincoln, Beethoven and Lenin.

“History teaches us humility,” says Dr. Mackowiak. “It is remarkable how much more we can accomplish in trauma care today, because of advances in medicine. At the same time, it is notable how far we still have to go in many other areas of our field.”

E. Albert Reece, M.D., Ph.D., M.B.A., Vice President for Medical Affairs at the University of Maryland and John Z. and Akiko K. Bowers Distinguished Professor and Dean at the University of Maryland School of Medicine, says the conference evokes the most essential elements of being a doctor. “At its core, medicine is about solving problems and unraveling the mysteries of diagnosis and treatment,” says Dean Reece. “This historic conference touches on that fundamental truth about our practice, and reminds us of the rich history of our profession. It is a pleasure to revisit these ideas each year at this event.”

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