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Posted on Sep 11, 2006 in Front Page Features, War College

What Really Killed Stonewall Jackson?

By J.D. Haines

On Thursday, May 7, Jackson’s wife, Anna, arrived with their five-month-old daughter, Julia. The sight of her husband’s mangled body and his difficulty breathing alarmed Anna. She later recalled that his condition “wrung my soul with such grief and anguish as it had never before experienced. … He looked like a dying man.”

Jackson smiled on seeing Anna and before falling back to sleep said, “I am very glad to see you looking so bright.” When he awoke, he took note of the concern on his wife’s face and said, “My darling, you must cheer up and not wear a long face. I love cheerfulness and brightness in a sickroom.” Anna tried to display a happy countenance, but her despair grew.

Dr. McGuire requested the assistance of Dr. Samuel B. Morrison, who arrived late in the afternoon. Morrison was a medical school classmate of McGuire’s and a relative of Anna’s. He had treated Jackson before the war and was recognized by the general upon his arrival. Morrison was unconvinced that Jackson’s labored breathing and pain in his side was due to pneumonia. Instead, he favored the diagnosis of prostration, a state of complete physical collapse.


Death of a Legend

McGuire and Morrison conferred and decided to send to Richmond for Dr. David Tucker, a leading authority on pneumonia. In the meantime, McGuire requested two other surgeons, Robert J. Breckenridge and J. Philip Smith, to join the medical team. Jackson was restless throughout Thursday night, calling out orders to his men. “A .P. Hill, prepare for action,” he shouted out on one occasion. “Pass the infantry to the front,” he commanded, as well as, “Tell Major Hawks to send forward provisions for the troops.”

The four physicians carefully examined Jackson Friday morning, but there was little they could offer for his persistent shortness of breath and chest pain. After Jackson spent another restless night, Dr. Tucker arrived from Richmond the morning of May 9 and confirmed McGuire’s original diagnosis. “Cupping” was recommended, and hot glasses were applied to the afflicted area to “draw out the blood.”

Jackson continued to decline, however, fading in and out of consciousness. When he awoke in the afternoon and saw several surgeons standing around his bed, he said, “I see from the number of physicians that you think my condition dangerous, but I thank God, if it is His will, that I am ready to go. I am not afraid to die.”

New research reveals that Stonewall Jackson likely died from a
pulmonary embolism, a direct complication of his arm amputation,
and not from pneumonia as was long thought to have been the case.

Following another difficult night, Jackson awoke on Sunday, May 10, completely exhausted. It was apparent to everyone that he could not last the day. Anna finally broke down sobbing and told Jackson there was no hope for his recovery. Jackson called for McGuire and said, “Doctor, Anna informs me that you have told her I am to die today. Is it so?” McGuire replied that there was nothing further the doctors could do. Jackson paused and responded, “Very good, very good. It is all right.”

After brief visits with little Julia and Major Pendleton, Jackson spoke his last words, “Let us cross over the river and rest under the shade of the trees.” He then died quietly at 3:30 p.m.

The Real Cause of Jackson’s Death

Some accounts claim Jackson was ill with a respiratory tract infection prior to the battle of Chancellorsville and point to the fact that he was wearing his raincoat on a warm day due to chills. However, none of the eight physicians who attended him in the last week of his life mention this history or describe any signs or symptoms suggesting a pre-existing respiratory tract infection.

While McGuire and the other physicians all agreed that pneumonia was the cause of Jackson’s death, modern-day analysis raises the more likely possibility of pulmonary embolism. The source of the so-called pleuro-pneumonia was presumed to be a lung contusion incurred during Jackson’s fall from the litter. However falling from a distance of only several feet, the ribs would absorb most of the blow and protect the underlying lung. There would also be external evidence such as bruising in a trauma serious enough to result in lung contusion. Yet McGuire and the other physicians found no evidence of external trauma.

Pleuro-pneumonia is a medical term rarely used today. Pleurisy occurs when inflammation involves the pleura (the outer surface of the lung). Pleuritic chest pain often accompanies pneumonia, thus the term pleuro-pnemonia. Sir William Osler’s 1892 edition of his classic textbook of medicine states, “Pneumonia is a self-limited disease, and runs its course uninfluenced in any way by medicine. It can neither be aborted nor cut short by any means at our command.”

Osler went on to say, “The first distressing symptom is usually pain in the side, which may be relieved by local depletion, by cupping or leeching” and “pneumonia is one of the diseases when a timely venesection [bleeding] may save life.”

Thus, according to medical opinion of the day, as evidenced by still being the general consensus 30 years later in Osler’s time, Jackson’s clinical presentation fit a diagnosis of pneumonia. His physicians cannot be faulted for their diagnosis and treatment since it was impossible at the time to confirm it by X-ray, technology obviously not yet available. However, 19th-century physicians were adept at eliciting the subtle physical signs of pneumonia, such as hearing a crackling sound in the lungs with the stethoscope or finding dullness to percussion of the chest. Yet neither of these classic signs of pneumonia was found by any of Jackson’s physicians.

In terminal pneumonia, its clinical course steadily deteriorates. But in Jackson’s illness, there were two distinct, sudden episodes of deterioration, separated by a period of apparent recovery – not the expected steady decline. These episodes occurred on May 3 and May 6, and both were described as being associated with the acute onset of chest pain, shortness of breath, fatigue and perhaps fever.

These symptoms are clearly consistent with pulmonary emboli, or blood clots that travel to the lungs. Among the numerous complications that can follow the amputation of an extremity are non-healing of the stump, infection, and thromboembolism – the formation of a blood clot within a large vein. According to Dr. McGuire, Jackson’s wound appeared to be healing and infection did not seem significant.

It is known today that an amputee is at significant risk for venous thromboembolism and pulmonary embolism. Immobilization of the patient following surgery can allow the blood to pool and clot within the veins. However, more important is the formation of clot in the large veins that are tied off during the amputation. This ligation leads to stagnation of blood in the veins, which in turn leads to a thrombus, or clot, that can then travel to the lungs and kill the patient. Even with today’s advanced technology, it is estimated that as many as half of pulmonary emboli are undetected by physicians. The current treatment and prevention of thromboembolism is accomplished by the use of blood thinning drugs like heparin and lovenox, obviously unavailable in Jackson’s case.

Given the state of medical practice in 1863, and lacking the medical technology available today, Jackson’s death seems unpreventable whether it was actually due to terminal pneumonia or, much more likely, pulmonary embolism. However, a close examination of Jackson’s symptoms reveals that he almost certainly died from thromboembolism – a direct consequence of the wound to his arm and its subsequent amputation – rather than the indirect cause of pneumonia, as has so long been presumed.

About the Author

Lieutenant Commander J.D. Haines is a Navy doctor currently stationed with the 3d Marine Division on Okinawa. He has published over 150 articles in historical and medical journals and is a board-certified family medicine physician.

For more on the Confederacy’s iconic general, see Battlefield Leader in the November issue of Armchair General magazine, on newsstands now!

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