Spring sunlight spilled onto the Confederate general’s deathbed. Around him were fellow officers, clergy and his wife, Anna. The physician in charge, Major Hunter Holmes McGuire, medical director of the Second Corps, Army of Northern Virginia, had made a Herculean effort over the previous week to save this man who had been his commander, mentor and friend, Lieutenant General Thomas J. “Stonewall” Jackson. Long a devout Christian, Jackson had always wished to die on a Sunday. He got his wish, joining his maker on the Lord’s Day, May 10, 1863, drawing his last breath around 3 p.m.

As a major and a doctor in the U.S. Army Reserve Medical Corps, I have been curious about what injuries and treatments—or lack thereof—brought Jackson to his end. What would a “historical” postmortem reveal? Herein is offered a modern physician’s clinical view.

At 9:30 on the night of May 2, 1863, while reconnoitering the lines during the Battle of Chancellorsville, Va., Jackson came under fire from nervous soldiers of the 18th North Carolina Infantry and was struck almost simultaneously by three shots, twice in the left arm and once in the right hand. Jackson’s initial attempts to keep upright with help from his aides were, in retrospect, a mistake, since they only hastened the onset of shock. A barely conscious Jackson was also twice given fluids by mouth, placing him at risk of choking on his own secretions (aspirating). To compound matters, he suffered three additional blunt, nonpenetrating traumas. First, while trying to regain control of his startled mount, he was hit square in the face by a tree branch. Then, after being transferred to a litter, he was dropped twice during transport. Both times he hit the ground hard, from a height of several feet, landing on his left arm, which had already been shattered by a musket ball, and on the left side of his chest. Those blows only worsened the extent of the gunshot injuries.

Jackson’s bullet wounds resulted in substantial blood loss. By the time Major McGuire finally reached him near Dowdall’s Tavern, the general was cold, clammy and quite pale. By any criteria, he was in shock. McGuire described the general’s clothes as “saturated with blood.” The blood was pink, implying the loss of arterial blood. This kind of blood loss is rapidly fatal unless stopped quickly. At that point, McGuire repositioned a tourniquet on the wounded left arm, which stopped the bleeding and temporarily saved Jackson’s life. It was a wonder that he was alive at all, given what had transpired over the preceding 90 minutes.

By 2 a.m., Jackson had been at the corps field hospital for nearly three hours, where he had been placed in a separate tent, warmed and given time to stabilize. His pulse and his color improved, and it was now time to examine his wounds under anesthesia. Chloroform was given by inhalation, and Jackson was carefully attended to by Dr. McGuire and three other experienced battlefield surgeons. The wound to the right hand was not life threatening, and the ball was extracted through a small incision on the back of the hand, after which the broken fingers were set and splinted. The injuries to the left arm were far more serious. The uppermost of the two bullets had entered the arm about three inches below the shoulder and exited out the back of the arm. In its wake were shattered muscle, a badly fragmented large bone of the upper arm (humerus) and a partially torn major artery to the arm (brachial artery). The wound to the lower portion of the arm had an entrance point just below the elbow. The bullet had corkscrewed through the forearm and exited just above the wrist. While this bullet had missed bone, it had macerated the muscles, tendons and soft tissues of the forearm. The arm was not salvageable and was amputated just below the shoulder. By 3 a.m., the surgeries had been completed. It was the best possible care available at the time.

Nine hours later the general was awake and coherent. The visible signs of shock had largely resolved, and his color was much improved, but Jackson complained of pain along the left side of his chest. This was a portent of what was to follow.

Because of concern about security in the Confederate rear areas, the general was transported via ambulance some 27 miles to Fairfield, the home of Thomas Coleman Chandler, early on the morning of May 4. On Tuesday, May 5, Jackson seemed to be much improved and the ever-vigilant McGuire was most pleased. Jackson had no apparent fever and was very lucid, though he slept extensively. He asked many questions about the recently concluded battle and the participants. His appetite was normal. The same favorable course followed the next day. Early on the morning of May 7, however, Jackson was awakened from his sleep by nausea, fever and intense pain in his chest. The pain was intensified by breathing (pleuritic).

When the sleep-deprived Dr. McGuire was finally awakened, he was stunned by Jackson’s dramatic deterioration. The general was heard to audibly gasp. His breathing was visibly labored, his heart rate had noticeably quickened and he now had such a fever that he had saturated his bedsheets. He had all the signs of what is now known as respiratory failure. Other physicians were called in for consultation, but all reached the same sad conclusion—the end was near.

The final cause of Jackson’s death was listed as “pneumonia.” While I concur with this, I think the autopsy report deserves expansion. Modern autopsy series have shown two patterns of mortality. In immediate fatalities, such as massive crush injuries or major penetrating wounds to the head or chest, the cause of death is typically a sudden, catastrophic event. In deaths that occur at a more remote time from the initial event, however, the cause is usually related to deterioration of multiple parts of the body over days or weeks—multi-organ systems failure. I think that this was indeed the case with Jackson. While pneumonia was the primary culprit, at least four other contributing factors likely played a substantial role in his death.

The first was shock. The human bloodstream consists of approximately five liters of fluid. Humans can tolerate the loss of modest amounts of whole blood without undue difficulty, but as the amount of blood loss increases, delivery of oxygen and nutrients to the cells of the body begins to fail, especially to the critical organs: the brain, kidneys, heart and lungs. In the average person, the loss of more than a third of the blood volume will result in the visible markers of shock, which were so apparent to Dr. McGuire when he first examined the general on the evening of May 2. Even though the shock was arrested by the timely actions of McGuire and his attendants, Jackson had already gone through a cascade of events that put him at major risk for subsequent critical organ failure.

A significant portion of shock survivors will develop, within three to five days of the initial resuscitation, kidney failure. The major function of the kidneys is to clear the body of the toxins that accumulate as a result of daily wear and tear. The accumulation of those poisons is much accelerated in a gravely injured person such as Jackson. The renal failure can have a multitude of effects on other areas of the body; in particular, it can compromise the ability to combat infections. The manifestations of kidney failure may also include delirium, a very prominent feature in Jackson’s behavior during the 72 hours preceding his death on May 10.

Another factor was aspiration. The body has a wonderful defense mechanism to avoid having food or fluids going down the “wrong way” into the breathing passages, or airways—the cough reflex. The cough reflex can be blunted by a number of factors, especially by anything that affects the level of alertness. When Jackson was still in shock he was orally given both alcohol and morphine. Without a doubt, some of his oral contents (secretions) were aspirated at that time. Those materials are laden with bacteria, and those bacteria are a cauldron of “bad actors” that are particularly hazardous to the lungs. The lung damage typically begins to occur 72 hours after the initial aspiration or later, as the number of anaerobic bacteria reach critical mass. When swallowed in ample amounts, they rapidly multiply and can literally eat tissue from the inside out and extend to the surface of the lung, which will cause pleurisy. Chest pain, often excruciating, was a dominant feature from May 7 until Jackson’s death three days later. Far and away, these are the most virulent and deadly of the bacterial pneumonias. Even current medical care has few answers for a pneumonia of that type. It was the coup de grâce for Jackson.

A third factor was pulmonary contusion. When sufficient blunt force is applied to the surface of virtually any area of the body, it is the underlying organs that often pay the price. The lungs are susceptible to such injuries, in part because the chest wall is relatively thin in comparison to other more heavily protected areas, such as the brain by the skull. On two occasions Jackson fell off his litter from a significant height, striking directly upon the lower left side of his chest, as well as the left arm. The force of the impact was enough that he likely bruised—contused—the wall of the chest. The impact of that injury likely penetrated the surface lining of the lung, the pleura, and the substance of the lung in the area of the left lower lobe. This was evidenced by the pain that he began to complain of, pleuritic pain, by the day after his initial injuries. These types of injuries are not only painful but often result in fluid accumulating in the damaged section of lung. Two major consequences of this fluid aggregation, or edema, are a defect in air exchange (oxygen in and carbon dioxide out) and a propensity toward secondary infections, especially pneumonias. If the process remains localized, the body can recover, but far too often the secondary infection worsens, then spills into the bloodstream (sepsis), and a generalized leak of fluid then occurs within the lungs, resulting in pulmonary edema or shock lung. The patient literally drowns in his own fluids. Recovery is very doubtful, even with the most sophisticated care.

Finally, in gunshot wounds and crush injuries, muscle is not only damaged but a certain portion is actually destroyed. This is called rhabdomyolysis. The byproducts of muscle death are released in microscopic amounts into the bloodstream. The intensity of the body’s response to this is largely dependent on the quantitative amount of muscle that has been injured. If enough muscle is destroyed, the kidneys are at risk of being poisoned, i.e., developing rhabdomyolytic renal failure. Muscle injury played a significant role in the renal failure that preceded Jackson’s death on May 10.

Could General Jackson have survived those cumulative system failures? History is a series of “ifs.” Had anyone known enough to stay the hands of those who with the best of intentions gave him liquids by mouth on the evening of May 2, I think the answer is yes. Oh, but for those acts of mercy.

Thomas J. Jackson was buried in Lexington, Va., on May 15, 1863. Dr. McGuire survived the war and settled in Richmond. He was instrumental in the resumption of studies at what would become the Medical College of Virginia and enjoyed a long and illustrious career.

 

Originally published in the May 2006 issue of Military History. To subscribe, click here