The demise of Stonewall Jackson: a Civil War case study, January 24, 2013

- [Donna Hirst] I'm Donna Hirst, the curator of the rare book room here at Hardin Library, and also the coordinator of the History of Medicine Society. And the History of Medicine Society has a monthly talk of which this is one. And ... We also have a mailing list that announces upcoming events, and so if you're interested in being added to the mailing list, there's a piece of paper at the back of the room where you can write your name and your email address and I'll add you to the list. It's a low traffic list, so ... That's ... I had a script and I forgot it. Now, so, I ... There are some chairs up here. Today, Wayne Richenbacher is gonna be talking to us about Stonewall Jackson and Civil War medicine. He's a cardiac surgeon who has indicated that he believes he was born about 100 years too late. He has a long standing interest in Civil War medicine and about two years ago, spent a week touring the beautiful state of Virginia, in search of sites important in the life of Stonewall Jackson. He was not interested in my telling you about his accolades, in cardiac surgery, but there are many, and you can find them on the website. - [Wayne Richenbacher] Let me ask you one question, Donna. Can I change the slides with the mouse? - [Donna Hirst] Yes. - [Wayne Richenbacher] Okay. Well, thank you very very much for coming out this evening, I was a little worried about turnout on a freezing cold January evening, but I do appreciate your taking the time to come. I want to start by apologizing, I think if you took the number of talks given by everybody in this room, they'd number in the hundreds, and I suspect most of you, like me, usually give talks without notes, we just stand up and talk and somehow that comes easy. But, this is not what I'm used to talking about, so as I got closer to the time to give this talk, I thought, it might be prudent if I actually wrote it out. And I apologize ahead of time because I'm going to actually read this to you, which is not usually what I do, but I wanna make sure I get it right tonight, so I'll start with that apology. Let me just make sure I have the, there we go. So, I'm gonna tell you a little bit about Stonewall Jackson, a little bit about the surgeon that took care of him, and then talk about his, Stonewall Jackson's injury and his demise, and then try to sum it up by giving you my take on all of that. So, Thomas Jonathan Jackson was born January 21, 1824, in Clarkesburg, Virginia. He was the third of four children, born to Julia Neale and Jonathan Jackson. Jackson's father and oldest sister Elizabeth, died of typhoid in 1826. Jackson's mother remarried to Blake Baker Woodson, but she died in late 1831 of complications of childbirth. Orphaned at age seven, Jackson and one sibling, his sister Laura, were raised by an uncle, Cummins Jackson, at Jackson's mill in Weston Virginia. Jackson's mill was a self-sufficient estate, however, it lacked preparatory education. Although unready for the rigors of post-secondary education, Jackson won an appointment to the US Military Academy, at West Point, in 1842. Tenacity and hard work served him well, and he graduated 17th out of 59 graduates in the class of 1846, with a commission as second lieutenant of artillery. Jackson served with distinction during the Mexican American War. He received several citations for gallant and meritorious conduct, and by the end of the war, had risen in rank to major. After the Mexican American War, army duty at Fort Meade, Florida, did not evolve to Jackson's satisfaction. He resigned his commission and accepted a teaching position, at the Virginia Military Institute, VMI, in Lexington, Virginia, in 1851. This is a photograph of the barracks at VMI, in front is the statue of Jackson, and in front of that are the actual artillery pieces that he used during his training of the students at VMI, and he referred to them as his apostles. As a professor of natural and experimental philosophy and artillery tactics, Jackson was described as an uninspiring and uninspired teacher. However, he was outstanding at demonstrating tactics during simulated military maneuvers. In August, 1853, Jackson married Elinor Junkin. However, she died giving birth to a stillborn son, 14 months later. In July 1857, Jackson married Mary Anna Morrison, and this is their home in Lexington. The union produced two daughters, Mary Graham who died at three months of age, in 1858, and Julia Laura, born in November 1862. Jackson remained in Lexington teaching at VMI until April 1861. After the battle of Fort Sumter, Virginia became the eighth state to secede from the Union on April 17th, 1861. Immediately thereafter, Jackson volunteered his services to the new Confederate state of Virginia. He was awarded the rank of colonel, and sent to Harper's Ferry to train new recruits that would ultimately become known as the Stonewall Brigade. When the first full-scale land battle of the Civil War took place at Manassas Junction, known as the first battle of Manassas of the first battle of Bull Run, on July 21, 1861, Jackson's Brigade of Virginians moved from the Shenandoah Valley on foot and by rail, in time to help repulse the Union army led by brigadier general Irvin McDowell. The Stonewall legend began, when Jackson's brigade came to the aid of brigadier general Barnard Bee, on Henry House Hill. Bee rallied his routed troops by shouting, there stands Jackson like a stone wall! Rally behind the Virginians! These are a couple of photographs of Henry House Hill as they are today, the left side is a monument to General Bee, who unfortunately, died during that engagement, and on the right, you see a fairly robust looking Jackson on his horse, Little Sorrel, at the apex of Henry House Hill. Jackson was injured during this battle, his left middle finger was struck and fractured by a bullet or shrapnel. A surgeon who first evaluated the injury recommended amputation. Hunter Holmes McGuire, the chief medical officer of the Stonewall brigade, prescribed local wound care and a palmar splint. With time and graduated finger exercises, Jackson was left with minimal deformity. Jackson was promoted to major general in October 1861, and placed in command of the army of the Shenandoah Valley. The valley campaign of the spring of 1862 showed Jackson to be a tactical genius. Vastly outnumbered in both men and material, Jackson's army staged a brilliant form of guerrilla warfare continually moving vast distances to engage and defeat federal forces under Union major general Nathaniel Banks. After defeating Banks in the Shenandoah Valley, Jackson's troops participated in the seven days battles in the peninsula campaign, the campaigns of northern Virginia and Maryland, all occurring during the summer and fall of 1862. Jackson commanded the left wing of the Confederate Army in the second battle of Manassas, the second battle of Bull Run, Harper's Ferry and the battles of Sharpsburg, also known as Antietam, and Fredericksburg. In October, 1862, Jackson was awarded the rank of lieutenant general and given command of the second core of the newly reorganized army of northern Virginia. Jackson was recognized as a brilliant military tactician, who was able to move his troops rapidly across great distances while using terrain to his advantage. He had an uncanny ability to predict Union troop movements and the behavior of Union commanding officers. He preferred to attack and pursue the enemy relentlessly. Yet, Jackson was a devout Presbyterian, preferred not to fight on Sunday, and has been described as shy, awkward, introverted, and very secretive. Jackson was unpretentious and eschewed the trappings of authority, although a strict disciplinarian, his performance in battle, including an utter lack of concern for his own well being, endeared him to those under his command. So now, let's talk about the surgeon that provided care for Jackson after he was injured. Hunter Holmes McGuire was born in Winchester, Virginia, at the north end of the Shenandoah Valley, on October 11, 1835. He was the fifth of seven children of Hugh McGuire and Anne Eliza Moss. McGuire's father, an accomplished ophthalmologist, established the first school of medicine, in the commonwealth of Virginia, known as the Winchester Medical College, in 1826. Hunter McGuire matriculated from the Winchester Medical College at age 20, and taught anatomy there for two additional years, before moving to Philadelphia to seek additional training at the Jefferson Medical College. When the abolitionist John Brown raided the federal arsenal at Harper's Ferry on October 16, 1859, approximately half the students studying medicine in Philadelphia came from the South. After John Brown was captured, tried, and hanged, his body was transported through northern cities, including Philadelphia. Differing political viewpoints led to an escalation and tension between the local residents, and the southern students. To avoid conflict, McGuire led approximately 300 students from Philadelphia to Richmond, where they were welcomed at the Medical College of Virginia, MCV. McGuire later moved to Tulane University in New Orleans. When Virginia seceded from the Union, in 1861, McGuire returned home to Winchester and enlisted as a private in the militia. I like this photograph, because that look is one that's cultivated by all surgeons. Even now. McGuire was sent to Harper's Ferry. But his medical background was recognized, and he was soon appointed surgeons of Jackson's first brigade. McGuire was given the rank and pay of a major of cavalry, and at the start of hostilities, was one of only 27 Confederate surgeons, out of 3,000 who actually had operative experience. As was customary in the medical service, McGuire retained the rank of major throughout the war, and was always addressed as Dr. McGuire. McGuire's duties extended far beyond the need to oversee the care of troops under Jackson's command. He was tasked with the development of policies regarding camp sanitation, and the requisition of medicines, instruments, and supplies. When campaigning began, medical equipment had to be transported, and sites selected for field hospitals near potential battlefields. A system of evacuation of wounded soldiers, including litters, litter bearers, and ambulances, were developed. Standards of care for the treatment of medical illnesses and battlefield injuries were defined, and a myriad of reports prepared for the surgeon general. The position demanded ingenuity and resourcefulness, as military medicine was poorly defined in the mid-19th century. Few military textbooks, medical textbooks, were available, and supplies were difficult to acquire, due to the Union naval blockade of southern ports. Further, the sheer magnitude and severity of illness and injury experienced in an organized army of this size, had never before been seen in this country. Yet, McGuire's organizational and surgical skills were readily apparent. Jackson noted in his official report after the first battle of Manassas, that Dr. Hunter McGuire has proved himself to be eminently qualified for his position, that of the medical director for the brigade. One of McGuire's more longstanding contributions to military medicine, occurred after the battle of Winchester in May, 1862. With Jackson's consent, McGuire unconditionally released seven captured Union surgeons, with the request that they return to Washington and urge the release of captured Confederate medical officers. Both armies adopted the policy that became known as the Winchester Accord. All physicians captured or imprisoned on either side were considered non-combatants, and were released and returned to their respective commands. This policy preceded the first Geneva Convention. Which in part, defines the non-combatant. And the formation of the International Committee of the Red Cross, which enforces the protection of non-combatants. When the army of northern Virginia was reorganized into two core, McGuire was named the medical director of the second core, a position he maintained throughout the remainder of the war. After Jackson's death in May, 1863, command of the second core was assumed by lieutenant general Richard Ewell, and later, by lieutenant general Jubal Early. In March 1865, Union major general Philip Sheridan overwhelmed the beleaguered second core in the Shenandoah Valley, capturing both McGuire and his wagon, containing his personal papers and medical records. The records are presumed to have been destroyed. Sheridan recognizing McGuire's role in the earlier release of Union surgeons, granted McGuire immediate release and a two week parole. Upon completion of his parole, McGuire traveled East to join the remnants of Lee's army, and was present when Lee surrendered at Appomattox. After the war, McGuire obtained a teaching position at MCV. His experience in the Civil War led to his being recognized as an expert in the administration of general anesthesia, and the surgical management of gunshot wounds. He specialized in abdominal and urologic surgery, gaining wide recognition for his development of the suprapubic cystostomy, a surgical treatment for bladder outlet obstruction. He became only the second surgeon to operate upon a ruptured abdominal aortic aneurysm. In December, 1866, McGuire married Mary Stewart of Staunton, Virginia. They had nine children, including two sets of twins. In March, 1877, McGuire opened the retreat for the sick, a charity hospital, and in 1883, he opened a 48 bed hospital, St. Luke's home for the sick, one of the first private hospitals in the South. In 1886, McGuire established a school of nursing at St. Luke's Hospital, only the second such school to be established south of the Mason-Dixon line. And the photograph on your left is the St. Luke's Hospital, and on the right is McGuire, he's the furthest one to the right, with the nursing staff and some of the interns at St. Luke's Hospital. In 1881, McGuire resigned his position at MCV. And in 1892, he helped establish a new medical school in Richmond, the University College of Medicine. When this school opened in 1893, McGuire was elected president and served as a clinical professor of surgery. In 1913, the University College of Medicine and MCV merged, under the Charter of MCV, currently known today as Virginia Commonwealth University. McGuire was a superb surgeon, a gifted orator, and recognized author. He was a strong advocate for continuing medical education, and a vocal proponent of medical organizations where collective wisdom could be used for the benefit of society as a whole. McGuire received two honorary law degrees and served as president of the American Surgical, the Southern Surgical and the American Medical Associations. On Monday, March 19, 1900, he suffered a left hemispheric stroke while traveling to his office at St. Luke's Hospital. He lost his ability to speak and developed right hemiparesis. He survived the event, and over time, was able to walk again. However, he never regained the ability to speak, and died on Wednesday, September 19, 1900. He is buried in Hollywood Cemetery in Richmond. So, with that background on the two key players, let's talk a little bit about the injury suffered by Stonewall Jackson. A defining moment ... The defining moment of the battle of Chancellorsville began with a daring plan developed by Lee and Jackson at the so-called Cracker Box meeting late on May 1, 1863. Jackson was to move the second core 12 miles on a circuitous route west, without the knowledge of Union forces, in hopes of striking the unsuspecting right flank of major general Joseph Hooker's army. The forced march through the wilderness by 28,000 men took most of Saturday, May second. When Jackson launched the attack at 5:15 p.m., Confederate forces took general Oliver Howard's 11th core by complete surprise. The Union forces were driven east toward Chancellorsville by the Confederate onslaught ... The attack slowing, only when battle lines became confused, and the sun set. As darkness fell, Confederate forces were situated roughly north and south across the east west oriented Orange Turnpike. And because it is important, it's now a major thoroughfare, route three, Orange Turnpike is here, Jackson was above the Orange Turnpike, north of it, when he was shot. Jackson wished to press the advantage, recognizing that Union forces would have the opportunity to reinforce their defenses overnight. At nine p.m., Jackson and his staff rode forward of the 18th north Carolina regiment, to reconnoiter. The 18th North Carolina was positioned north of the Orange Turnpike, the 23rd North Carolina was positioned further forward, east, as a skirmish line. To avoid exposure to enemy fire, Jackson and his staff roughly followed the mountain road and unimproved track that lay just north and parallel to the Orange Turnpike. Small arms and cannon fire began. And as Jackson and his staff attempted to return to their own lines, they were mistaken for Union cavalry. Soldiers in the 18th North Carolina regiment fired upon the group. In the melee, a total of 11 riders and 14 horses were struck down. There are at least five firsthand accounts of Jackson's wounding and the moment immediately thereafter. However, the descriptions of Jackson's wounding, initial treatment, and evacuation, are not entirely consistent. The variance and perceived recollections can be attributed to the chaotic conditions during the brief but violent engagement. Staff members tried to assess and tend to Jackson's wounds while protecting him, and themselves, from small arms and artillery fire. Despite the full moon, the dense undergrowth impaired visibility. Battle lines were confused, and opposing armies were positioned within earshot of each other before the firing began. Brigadier general James Lane was a brigade commander at Chancellorsville, in his account, he confirms that then major John Barry, the commander of the 18th North Carolina regiment, was unaware of Jackson's move to the front. Had ordered his men to fire upon approaching horsemen, and had pronounced the subsequent cry of friends, to be a lie. Lane acknowledges that the 18th North Carolina wounded both Jackson and general A. P. Hill. Major Benjamin Watkins Lay, who at the time was serving on A. P. Hill's staff, was caught in the same fire, as Jackson and his staff. Uninjured, but having had his horse shot out from under him, he was instructed by Hill, who was aware Jackson had been wounded, to go for a surgeon and an ambulance. Although an ambulance was at least a mile away, Lay brought an assistant surgeon, a Dr. Barr, a stretcher, and litter bearers to Jackson. Lay describes Jackson as being carried by litter, but notes that two litter bearers abandoned the litter when cannon fire increased. Jackson tried to walk, but became faint and was placed back on the litter. While walking through the woods, one litter bearer fell when he entangled a foot in a grape vine. Jackson was dropped onto his broken arm. The group subsequently met a Dr. Whitehead, who had procured an ambulance. Whitehead administered whiskey and Jackson was transported to the Chancellor's house, where Dr. McGuire joined the group. Major Marcellus Mormon of the Stuart Horse Artillery batallion confirms the intermingling of battle lines, and that Jackson was north of the Orange Turnpike, when wounded by the 18th North Carolina regiment commanded by Barry. Mormon was passed by four men, carrying Jackson, on a litter. When he recognized Jackson's voice in the dark Mormon ordered a soldier removed from an ambulance and Jackson be put in. Captain R. E. Wilbourne, provides a much more detailed account of the actual wounding, and severity of Jackson's injuries. Wilbourne states that Jackson's entire party, with the exception of himself and a member of the signal core, lieutenant William Win, had been killed, wounded, or dispersed. Wilbourne and Win helped Jackson down from his horse, and Wilbourne used a penknife to cut away the India rubber coat, dress coat, and two shirts from Jackson's bleeding arm. He bound a handkerchief tightly above and below the wound and placed the arm in a sling. Jackson was given whiskey and an immediate evacuation ordered as the federal line was not more than 150 yards to the east. Captain Lay arrived at the litter and Jackson was placed upon it. One litter bearer was shot through both arms by artillery fire, dropping the litter. Jackson fell to the ground, landing on his wounded side. He began, quote, bleeding afresh. Wilbourne went to seek McGuire and an ambulance, as Jackson was placed in the ambulance, Wilbourne left to report to Lee. Although McGuire was not with Jackson when he was shot, he met the evacuation party shortly thereafter. His account provides detail about Jackson's wounds, the treatment thereof, and subsequent care. Writing in 1866, McGuire describes an initial litter bearer as having been struck down. The result, loss of support, caused the general to be thrown to the ground. Jackson was placed back on the stretcher and carried a few hundred yards to where McGuire met Jackson with an ambulance. A preliminary examination by McGuire showed Jackson was mentating normally, but his hands were cold, skin clammy, face pale, and lips compressed and bloodless. Hemorrhage had begun anew, but was controlled with digital pressure on the artery. The handkerchief tourniquet had slipped and was readjusted, McGuire kept digital pressure on the brachial artery. During the ambulance ride to the core field infirmary, at the Wilderness Tavern. Jackson was also given additional whiskey and morphine prior to departure for the core infirmary. The ambulance arrived at the wilderness tavern, located four miles to the rear, shortly after 11 p.m. Dr. Harvey Black, an internist and the surgeon in charge of the field hospital, had prepared a warm tent to receive Jackson. On arrival, Jackson was given additional whiskey and water. These are two slides that show the wounding site, both as it appeared in the late 1800s, and then as it does today, the Jackson Rock, was placed in 1879 at the site at what was thought to be the shooting. In retrospect, it's probably about 80 yards to the south of where that actually occurred, and the tree to the right is just about where the Orange Turnpike is, it runs this area, so you're actually looking east, toward where the federal line was. This is the rock as it appears today. Thinking that a more fitting memorial was required, this would be the Orange Turnpike, and you can see the rock in the rear, but now, today, there's a much larger memorial, and you can see as it appears just a year or so ago. Immediately adjacent to and visible from that Orange Turnpike. At two a.m. Sunday, May third, five hours after he was wounded, McGuire accompanied by doctors Black, Wall, and R. T. Coleman, examined and treated Jackson's wounds under chloroform anesthesia. Two or three facial lacerations were dressed with isinglass plaster. The wound in his right hand was explored, and a round the ball, from a smooth bore Springfield rifle removed. The ball had entered the right palm in the middle of his hand and fractured the second and third metacarpals. The ball was lodged under the skin, upon the back of his hand. And for those of you who are not familiar with the anatomy, I thought I'd put a couple pictures from a Frank Netter atlas. The hand injury on the right fractured the second and third metacarpals, the metacarpals are in the palm of the hand, so the junction between the palm of the hand and the fingers would occur at the end of the metacarpal and the proximal phalanx. So he had fractures to the second and third metacarpal, the ball entered the front, and was found at the back, under the skin on the back of his hand. There were two left arm wounds. The forearm wound is described as several inches in length. A ball having entered the outside of the forearm, an inch below the elbow, came out upon the opposite side just above the wrist. So you had an injury ball entering just above his elbow on the outside, exited the forearm just above the wrist. The second left arm wound occurred three inches below the shoulder, it was a through and through injury that fractured both the humerus and injured the brachial artery. So, even though this is a right arm, the injury occurred at approximately this level, the humerus is the large bone in the upper arm, the brachial artery provides all of the blood flow to the upper extremity, so the fracture injury occurred at about this level, and the brachial artery was either partially injured or transected at the same location. McGuire amputated Jackson's left arm two inches below the shoulder, using what is described as the circular technique, and we'll talk about that a little bit more in a moment. Four surgeons were present during this operation. McGuire was the operating surgeon, Coleman served as the anesthesiologist, chloroform was administered using the open drop technique. Black watched Jackson's pulse, Walls assisted McGuire, and ligated blood vessels. Captain James P. Smith, a theology student at Richmond, held a light above the operating table. The operation proceeded uneventfully, with quote, slight loss of blood. Jackson awakened a short time after his operation and spoke with clarity to one of his agitants. He consumed coffee a half hour later, and then slept for nearly six hours. Jackson's core chaplain, Reverend Beverly Tucker Lacey, recovered Jackson's arm and had it buried in the family plot at Ellwood, his bother's nearby estate. At nine a.m., Sunday, May third, Jackson awoke, took nourishment, and displayed a cheering resilience. At ten a.m., he complained of pain in his right side. Jackson thought this might've been caused by his having struck a stone or stump of a sapling when he fell from the litter during his evacuation. On examination, McGuire could find no evidence of injury. There was no bruise or indication of broken ribs. Breathing was normal, cold cloths were applied locally. By eight p.m. Sunday evening, the right sided pain had resolved. Jackson seemed to be doing well, and inquired about details of the ongoing battle. To avoid capture by Union forces, and to continue his convalescence, Jackson was moved from the core hospital at the Wilderness Tavern. Jackson was sent to Fairfield, the Thomas Coleman Chandler house and plantation at Guiney Station, in anticipation of rail transfer to Richmond. There is some inconsistency in published accounts as to the date of the transfer. Most authors note the move occurred on Monday, May 4. In a well-researched book describing Jackson's final days, the military historian, Chris Makowski, also notes the transfer occurred on Monday, May 4. Other authors note that Jackson was transferred to Fairfield on Tuesday, May 5th. McGuire's recollection published three years after the events, states that Jackson was transferred to Guiney Station on Tuesday, May 5th. Jackson was moved via ambulance and during what is described as a grueling 14 hour, 24 mile ride, over difficult back roads in a horse-drawn ambulance, the transfer consumed the majority of the day. McGuire was ordered by Lee to turn his duties as medical director over to the next ranking physician, and to continue to provide care for Jackson. With McGuire and Jackson's servant, Jim Lewis, at his side, Jackson began the journey at six a.m. En route, Jackson complained of the afternoon heat and nausea. Jackson believed in hydrotherapy, also known as the water cure, and he requested that wet towels be placed on his abdomen. After a towel was placed, the nausea resolved. The ambulance carrying Jackson arrived at the Chandler House at eight p.m. McGuire placed Jackson in an adjacent office building, rather than the main house, with other injured soldiers. This decision was based on Jackson's desire to avoid disturbing the other soldiers, and McGuire's concern about the presence of erysipelas in the main house. And this is a photograph taken on 120 years or so ago, shows the Chandler Plantation, this is the main house at the back, the main house no longer exists, it's simply a foundation marking the ground. This is a smokehouse that also no longer exists. The office building where Jackson was cared for remains, and the sort of orienting feature are these two chimneys. On arrival, Jackson felt well enough to eat bread and tea, with evident relish. This is the Chandler plantation as it appears today, you can see those two chimneys from the previous slide. The room that Jackson was cared for is in the door on the immediate right, this is the bed, it's a rope bed that he was cared for in, the same bed. We are also told that this coverlet at the bottom of the bed was the one that was used for Jackson, the original one, directly across from the foot of the bed was a mantel above the fireplace, and the clock that was there when Jackson was in the room, is still in its original position. On Tuesday and Wednesday, May 5 and 6, Jackson appeared to be recovering uneventfully. His right hand wound and amputation stump were healing well. To quote McGuire, union by first intention, had taken place and to some extent, in the stump and the rest of the surface of the wound exposed, was covered with healthy granulations. The wound in his hand gave him little pain, and the discharge was healthy. Simple lint and water dressings were used, both for the stump and hand, and upon the palm of the latter, a light, short splint was applied. Jackson was taking nourishment, mentating normally, and even inquired as to the length of his convalescence, in anticipation of his return to the field of battle. In the early hours of Thursday, Mar 7, Jackson's condition deteriorated. He awoke at 1 a.m. complaining of nausea and pain in his right side. Jackson did not wish to disturb McGuire, and asked his servant, Jim lewis, to place a wet towel over the affected area. Over time, the pain increased, and became chloritic in nature. Jackson developed shaking chills. McGuire first became aware of Jackson's decline on the morning of Thursday, May 7. Based upon Jackson's symptoms, McGuire diagnosed pleuropneumonia of the right side. McGuire and other surgeons involved in Jackson's care attributed it to his fall from the litter. The assumption was that the lung was contused with extravasation of blood in his chest. The shock and loss of blood prevented any ill effects until reaction had been well established, and then inflammation ensued. Jackson was given morphine, and from that point on, his staff noted a change in sensorium. He was in turn stuporous or delirious with only occasional brief periods of lucidity. Cups were applied in an attempt to bring more blood to the affected region. Mercury with antimony and opium were administered. Mary Anna Jackson and their daughter Julia arrived at noon. In her account, she notes the desperate pneumonia, which was flushing his cheeks, oppressing his breathing and benumbing his senses. He had to be aroused to speak to me, but he was too much affected by the morphiate to resist stupor. However, Jackson's spirits were buoyed by the arrival of his family, and according to McGuire, joy at the presence of his wife and child was very great. Dr. Samuel B. Morrison, Jackson's brother-in-law and the chief surgeon of Early's division, arrived later that day. He found Jackson breathing badly, suffering much pain, and at times delirious. He and McGuire consulted and decided to summon Dr. David H. Tucker, an authority on pneumonia from Richmond. On Friday, May 8, Jackson's wounds were dressed, and although the quantity of the discharge from them had diminished, the process of healing was still going on. Despite the reduction in flank pain, Jackson's difficulty breathing persisted. McGuire sought consultation with additional surgeons, doctors Breckenridge and Smith of the army medical core. Blisters, the topical application of a caustic substance, were applied as another treatment for pneumonia. By Saturday, May 9, Jackson was exhausted. His breathing was labored, and his respiration shallow and rapid. He developed a fever, and according to one author, a cough productive of quote, putrid sputum. Dr. Tucker arrived from Richmond. He felt that all that human skill could devise was done to stay the hand of death. On Sunday, May 10, Jackson was in a stupor. His breathing was quite labored and his pulse rapid, thready, and weak. His face was emaciated. It was clear to the physicians involved in his care that Jackson would not survive the day. Although Jackson refused brandy and morphine in an effort to keep his mind clear, by the afternoon, he was nearly unconscious. His breathing was described as difficult and stertorous. At 3:15 p.m., he uttered the words, Let us cross over the river, and rest under the shade of the trees. He then expired. At his request, Jackson was buried in Lexington, Virginia. And this is a lithograph of his wife and daughter visiting his grave in Lexington. This is another drawing of Robert E. Lee visiting his graveside in Lexington, and actually, it's probably not too far from true, because after the war, Robert E. Lee accepted a position as president of the Washington College in Lexington, subsequently known as the Washington and Lee University. And the president's mansion or home, was just a few blocks from the Stonewall Jackson cemetery, where Stonewall was buried. The marker on the left shows Jackson's name, but also states that his remains were removed, and they were removed from that small family plot to the center of the cemetery, where a larger monument with him depicted at the top, is located. So, what can we discern from all of this? I think Stonewall Jackson orchestrated a brilliant tactical maneuver, when he led the second core of the army of northern Virginia. On a day long march, via back roads, to strike the unsuspecting right flank of Hooker's army, as they were preparing their evening meal. The Confederate soldiers drove the Union army several miles east through dense woods, and nearly impenetrable underbrush. Jackson wished to move forward, even as darkness fell. His ill-advised foray between battle lines led to his being badly wounded by his own troops. While difficult battlefield conditions and friendly fire are known in armed conflicts even now, the care provided to Jackson after he was wounded was exemplary by the standards of the day. Under fire, and in complete darkness, captain Wilbourne exposed the wound in Jackson's left arm, and controlled arterial hemorrhage with a makeshift tourniquet. Dr. Barr arrived shortly thereafter, and could be criticized for not having applied a standard tourniquet, as is depicted here. However, the handkerchief had stopped the bleeding from Jackson's brachial artery, and the need to move Jackson out of harm's way was paramount. Jackson was given whiskey as a stimulant, and rapidly evacuated by litter and ambulance, to a nearby aid station, and on to a field hospital at the Wilderness Tavern. Hemorrhage was controlled, Jackson was protected from further harm, and a restorative had been administered. Jackson was resuscitated in accordance with contemporary guidelines, and by 2 a.m., May third, he had stabilized to the point where his wounds could be examined. McGuire obtained verbal consent, and the examination began under chloroform anesthesia. Chloroform was first used in 1848, and was employed extensively during the Crimean War in the mid 1850s. Chloroform is relatively non-flammable, will not explode and was the anesthetic agent of choice in 76% of cases during the Civil War. McGuire and his staff reportedly used chloroform anesthesia in more than 28,000 cases, with housing. The Civil War surgeon was given four tasks when managing a wounded soldier. The wound was to be examined in order to obtain a correct knowledge of its extent and nature. Second, foreign bodies, including the projectile, pieces of clothing, grass and dirt, were to be removed. Bone fragments from comminuted fractures were also extracted. Third, adjustment of lacerated structures and fourth, the application of primary dressings. Wounds could be probed with a variety of instruments, although most surgeons favored digital examination in an effort to avoid causing additional injury from blunt misguided dissection. Secondary incisions were to be avoided, but in the case of Jackson's right hand wound, the ball presented beneath the skin on the dorsum of the hand. McGuire extracted the ball using a secondary incision. If a secondary incision was used, it was suggested that the projectile be fixed in position, and the incision oriented longitudinally, so as to avoid injury to adjoining structures. Indications for amputation included extensive soft tissue injury, an injury involving a joint, a comminuted or compound fracture of a long bone, or arterial injury. Survival rates in patients who underwent primary amputation, those defined as having been performed within 24 to 48 hours of surgery, were higher than survival rates in patients who underwent secondary amputation, more than 24 to 48 hours after injury. McGuire surmised that Jackson's arm might require amputation, and informed Jackson of that possible eventuality, prior to the induction of anesthesia. An expeditious, uneventful amputation was performed, approximately five hours after Jackson was wounded. Amputations were performed using one of three techniques. Circular, flap, or oval. And this is one of the military medical manuals at the time. The circular technique is depicted on the left. The skin and soft tissues are incised in circular manner around the limb to be amputated, and then retracted proximally to expose the bone, the bone is divided at a higher point to allow some soft tissue coverage. In one of the manuals, it describes leaving that wound open, in others, it describes closing the wound, but it creates a fairly small wound compared to either the oval amputation, or the flap amputation. The flap and oval amputation are, provide a little bit better soft tissue coverage over the stump of the bone, which is the primary goal of the amputation, of the performance of the amputation. The goal in each instance was to remove damaged tissues, ligate vessels, and provide adequate soft tissue coverage to protect the end of the transected bone. Edges of the wound are brought together by ligatures, adhesive strips, or bandages. Although there was some disagreement as to the preferred technique, it was generally recognized that the circular operation made a smaller wound, and arteries cut transversely were more readily accessible and easier to control. Blood loss was reduced, and a compact stump gave a less extensive suppurating surface, and bears the jars of transportation better. Flap technique, either single or double, permitted the surgeon to salvage greater limb length. However, the operation took longer, and was technically more demanding, particularly when performed under low lighting conditions. The decision as to which technique to employ seems to be one of surgeons' preference. In Jackson's case, McGuire utilized the circular amputation technique. Although wound edges were approximated, the purpose was not to obtain union by adhesion, in contradistinction, to wound closure by today's standards. Rather, the goal of wound approximation was simply to prevent avoidable irritation and malposition of parts, during the subsequent stages of cure by granulation and cicatrization, scar formation. Although some wounds healed without suppuration, a certain degree of suppuration was deemed inevitable. Dressings were usually changed once a day, and by all accounts, Jackson's wounds were granulating well, with healing by first intention. Although scant, the discharge was healthy. Healing by the first intention denotes the lack of suppuration, and at no time did McGuire express any concern about Jackson's developing, either of the two dreaded wound healing complications, erysipelas, or hospital gangrene. Extremity wounds were found in 70% of wounded soldiers who survived to reach a field hospital. Amputations accounted for approximately 75% of all operations performed during the Civil War. The medical and surgical history of the war of the rebellion, a compilation primarily of Union medical records, published soon after the war, reports 5456 cases of arm amputation for shot injury. The outcome is unknown in 183 patients, of the 5274 cases in which the outcome is known. 1246 died, for a mortality rate of 23.6%. Just as a sidebar, one of the things that's fun in looking through this collection, is that it lists every single soldier who was injured, a day to their injury, the treatment thereof, and the outcome. Although again, this is mostly a listing of Union soldiers, if you look carefully through the upper extremity amputations, you'll find a listing for lieutenant general Jackson, injured on May third, on the left arm, brachial artery severed, fracture of the hand, contusion of the side, with death on May 10, 1863. The timing of amputation influenced the outcome. The mortality rate for delayed or secondary amputation for extremity amputations of all types is approximately double that of primary amputation. According to a report in the Confederate states medical and surgical journal, published in 1864, the mortality for primary amputation of the upper arm was 14%, versus 37% for secondary amputation. According to data in the medical and surgical history of the war of the rebellion, the mortality rate for secondary amputation of the upper arm was 33%, or 15% greater than that after primary amputation in the same region. Five days after he was wounded, and four days after his arm was amputated, Jackson developed right sided pain, labored breathing, fever, and a change in sensorium. McGuire diagnosed right pleuropneumonia, attributable to Jackson's fall from the litter during his initial evacuation. This portion of Jackson's clinical course has served as a long-standing source of contention. Unfortunately, McGuire's detailed notes concerning Jackson's injury and death were seized by the Union army under general Sheridan in the Shenandoah Valley, in March 1865. A Mr. Samuel Kirk, a historian at the Armed Forces Institute of Pathology, was unsuccessful in his attempt to locate Dr. McGuire's lost records in the National Archives, in 1963. Records and reports of the Confederate medical core stored at the office of the surgeon general, Samuel P. Moore, were destroyed when Richmond was burned, April second, 1865. Thus, we are left with a single account, published by McGuire, in 1866. This account is written after the fact and contains far less detail than would've been included in a daily assessment. McGuire notes the onset of chest pain and nausea, but does not specifically mention fever, cough, or sputum production, which would presumably accompany pneumonia. When Jackson complained of the right sided chest pain on May third, McGuire notes no chest contusion or apparent rib fracture. When Jackson's condition deteriorated on May 7, McGuire does not describe any physical findings making no reference to the presence or absence of breath sounds or dullness to percussion. If we assume that Jackson had developed pneumonia, its onset may predate his battlefield injury. It is known that he slept on the ground, perhaps without a blanket, on the night of May 1. He is described as having developed a cold prior to the flank march. When captain Wilbourne exposed Jackson's left arm wound, he cut through four layers of clothing that Jackson was wearing, despite midday temperatures in the 80s. Any underlying pulmonary condition might have been exacerbated by the use of chloroform anesthesia. This inhaled agent is associated with pulmonary morbidity, hence the recommendation that it only be used in well-ventilated areas. It is also conceivable that the chloroform used contained impurities, not an uncommon circumstance at that time. Some have argued that pneumonia might have developed as a result of the wet towels placed upon Jackson's torso on May third and May 7. Sir William Ostler and his classic text, the Principles and Practice of Medicine, published in 1892, notes that pneumonia sometimes promptly follows a sudden chilling or wetting. McGuire, however, refutes this theory, when he states the disease came on too soon after the application of wet cloths. Ostler does describe contusions pneumonia as pneumonia that follows traumatism with great frequency more particularly injury of the chest. McGuire in his examination of Jackson on May third, noted no evidence of chest wall injury. Furthermore, when Jackson fell from the litter, he struck his left, not his right side. The medical and surgical history of the war of the rebellion records 61,202 cases of pneumonia during the war. Of these, 14,738, 24.1%, died making pneumonia the third most common cause of death behind diarrhea, dysentery, and continued fevers during the Civil War. In this pre-antibiotic era, Ostler noted that pneumonia is a self-limited disease, and runs its course uninfluenced in any way by medicine. It can neither be aborted or cut short by any means at our command. He further noted that pneumonia is one of the most fatal of acute disease, with a higher mortality rate occurring in the southern states. Although Ostler notes there is no specific treatment for pneumonia, in the mid-19th century, patients were treated with oral cathartics, including antimony, opium, blistering agents, and cupping. Blood letting had all but been abandoned before the Civil War. Jackson was treated with bed rest, brandy, whiskey, antimony, morphine, cupping, and blistering. As his condition worsened, McGuire sought consultation with additional physicians, including Dr. Tucker, a recognized expert in the management of the patient with pneumonia. All concurred with the diagnosis and felt that everything that could be done to treat the disease, was being accomplished. Physicians recognized the futility in managing patients with pneumonia, and were so familiar with the disease process, that they could accurately predict its clinical course. Jackson himself recognized the dire circumstance when on May 9, the day prior to his death, he commented to McGuire, I see from the number of physicians that you think my condition dangerous. Jackson's cause of death could not be confirmed at autopsy as a post-mortem examination was not performed. In retrospect, chronic fatigue, constant exposure to the elements, and dietary deficiencies related to a long, hard campaign, undoubtedly left Jackson less able to tolerate life-threatening gunshot wounds. This is the Chancellorsville portrait taken about a week and a half or so before he was injured, and two weeks before his death, and I think you would all agree that as we say, he looks much older than his stated age of 39 years, at that point. Despite expeditious first aid and prompt surgical care, he experienced significant blood loss and exhibited signs of hemorrhagic shock. However, his right hand wound and left arm amputation stump appeared to be healing adequately. Most would agree, that wound sepsis was not a direct contributor to his death. Pneumonia, of whatever etiology, even in a non-compromised patient, would prove lethal in the pre-antibiotic era. In conclusion, Jackson was an audacious military tactician, who despite his eccentricities, was revered by his troops. His success on the battlefield, coupled with his early death, resulted in a legend that grows to this day. McGuire and the other surgeons involved in Jackson's care had no ability to administer intravenous fluids, had no access to blood component therapy. They had no radiographic imaging modalities, and were unable to perform any laboratory studies. They had no understanding of germ theory, or the benefits of surgical antisepsis. Let alone, the ability to perform complex vascular or orthopedic reconstruction. Antibiotics did not exist, and techniques to enhance pulmonary performance were lacking. Yet, Dr. McGuire and his colleagues did provide expeditious and diligent care that met or exceeded management standards of the time. Even with a century and a half of hindsight, it is difficult to imagine anything that McGuire could've done to alter the course of Stonewall Jackson's inexorable demise. Again, I greatly appreciate your taking the time to come out this evening, and we have a couple of minutes left, I hope, if you have any questions, I'd be more than happy to try to answer them for you. Thank you. - [Audience Member] How old was McGuire at the time of - [Wayne Richenbacher] At the time of? - [Audience Member] That he was treating Jackson, how old was he then? - [Wayne Richenbacher] He was very young. So he was born in 1835, so he'd be 28 at the time he was taking care of Jackson. In fact, when McGuire was first assigned to Jackson's Brigade, at Harper's Ferry, he walked into Jackson's tent as he was ordered, and Jackson was kind of taken aback by the fact that this 26 year old physician was assigned to his brigade. And informed McGuire that he should go back to his tent and await further instructions. At that point, then, Jackson sent a courier to Richmond to confirm this assignment. And a week later, when the courier returned to Harper's Ferry, the confirmation was affirmed and McGuire became the brigade surgeon. Then, they developed a, remainder of at least Jackson's life, very meaningful relationship and were oftentimes seen together, they actually shared a tent at times. - [Audience Member] Have you done any other famous soldiers in this little way you looked at their medical histories, or have an interest in somebody else? - [Wayne Richenbacher] Sure. - [Audience Member] How about Dan Sickles? - [Wayne Richenbacher] That was one I am not. No, there are lots, and the nice thing, is that many of them are very well documented. And one thing I should acknowledge is the assistance of the librarians here and at the main library in helping me find a lot of these very sort of difficult to locate sources, but there's a lot of information available, so I'll put him on the list. - [Audience Member] Who else is on your list? - [Wayne Richenbacher] Who else? - [Audience Member] Yeah, just a couple of ... - [Wayne Richenbacher] Well, it's, sort of you have the multi-year plan, and of course, Robert E. Lee had a stroke. Like to know more about that. That's probably very well described. Longstreet was shot in the neck and survived, by some accounts, a tracheal injury, or at least a laryngeal injury, which even by today's standards, is difficult to survive. There are many others. - [Audience Member] did they ligate the veins and arteries, or did they use cautery, or ... - [Wayne Richenbacher] They ligated them, and they, at the time, there was sutraligature available to the Union army, sutraligature was oftentimes not available to the Confederate army, because of the blockade and the problem with supplies. Most of the medical supplies available to the Confederate army were captured from the Union army. But the ligature story is interesting, again, by itself, and always, these little sidebars are probably more interesting than the main story. The Union army used ligatures, which were of course, not sterile. In fact, the surgeons used to put the sutures through the buttonhole on their coat while they were performing amputations, to keep them handy and organized. In the Confederate army, because of lack of availability of sutraligatures, they would oftentimes use horsehair. Horsehair is very stiff, and so to make it a little more pliable and able to be used as a ligature, they would boil them. So, not knowing that boiling actually sterilizes them, they were actually imparting a little bit of some sterility to the operation. But they did ligate them, they then left the ends hanging out of the wound and they would tug on them a little bit each day, hoping that at some point, that would slough and that suture could be withdrawn from the wound, which then was met oftentimes, a secondary hemorrhage, which is a whole different problem by itself. Other questions? Again, thank you very, very much for coming this evening, I appreciate it. - [Donna Hirst] And as a thank you, I would like to give you a copy of.. - [Wayne Richenbacher] Thank you very, very much, I appreciate it. And thank you for the invitation.