Tuesday, October 9, 2007

Medical Department #8 - Second Opinions

In late July and early August, I posted blog entries (here and here) about a recent and interesting article in the journal, Military Medicine, about a new hypothesis as to what may have ultimately caused Stonewall Jackson's death after his wounding by friendly fire at Chancellorsville. The article - and my subsequent interview with one of the authors, Dr,. Timothy Koch - formed the basis for my most recent "Medical Department" column in The Civil War News (October 2007). The column has since appeared in print, so it's my pleasure to now post the full text of the column on my blog.

Again, one of the advantages of posting the column on the blog is that I can now provide hyperlinks to relevant information and illustrations in the column; in this case, readers will be able to access abstracts of previous articles in the medical literature about Stonewall Jackson, as well as encclopedia entries about personalties and terms that come up in the article.

"Second Opinions"

by Jim Schmidt

from the October 2007 issue of The Civil War News

Doctor: Your tonsils gotta come out.
Patient: I wanna second opinion.
Doctor: Okay, you're ugly, too.

When it comes to "second opinions," few Civil War personalities have been poked and prodded as much as Stonewall Jackson, especially as regards conclusions about what really caused his death after his friendly-fire wounding at Chancellorsville. By turns, several hypotheses have been put forward, including an abscess of his lung, pneumonia, or a pulmonary embolism. A few of the more recent reports include:

Albin MS, "The wounding, amputation and death of Thomas Jonathan "Stonewall" Jackson: Some Medical and Historical Insights," Bull Anesth Hist, 2001 Oct;19(4):1, 4-7, 15-6.

Haines JD, "What killed Stonewall Jackson?" J Okla State Med Assoc, 1998 Jul;91(4):162-5.

Layton TR, "Stonewall Jackson's wounds," J Am Coll Surg, 1996 Nov;183(5):514-24.

Recently, two more physicians have thrown their hat into the ring with a new hypothesis. In a recent paper, “Chronic gastrointestinal symptoms of Thomas ‘Stonewall’ Jackson following Mexican-American War exposure: a medical hypothesis,” (Military Medicine, Jan 2007, Vol. 172, No. 1, pp. 6-8), Drs. Timothy R. Koch and Joseph B. Kirsner offer a new explanation, namely Jackson's complications from chronic peptic ulcer disease.

It's an interesting hypothesis, made even more interesting in that the authors tie it to their experience in treating veterans of the Persian Gulf War, many of whom exhibited symptoms of chronic heartburn or dyspepsia and were diagnosed with infections of Helicobacter pylori, a bacteria that infects various areas of the digestive tract and is a contributing factor to peptic ulcers, gastritis, and even cancer.

The authors note that “Stonewall” Jackson was born and raised in an area of what is now West Virginia that has a high prevalence of H. pylori. Jackson suffered symptoms of chronic dyspepsia, especially after his service in the Mexican-American War. For relief, he tried various remedies, including what would become known as the “Sippy diet” – a regimen of foods (cereals, eggs, and crackers) and fluids (milk and cream) intended to neutralize gastric acid.

On Saturday, May 2, 1863, Jackson received a bullet wound to the left arm at the battle of Chancellorsville; he underwent amputation of the left arm below the left shoulder and died a week later with a diagnosis of pleuropneumonia. But, since the records of Jackson’s post-surgical course are incomplete, the door has been open to a number of possible theories. Drs. Koch and Kirsner believe that Jackson’s chronic dyspepsia - and his death – might be related to chronic ulcers caused by H. pylori.

Both doctors are experts in the field of gastroenterology. Dr. Kirsner received his medical degree more than seventy years ago and is about to celebrate his 98th birthday. He still goes to work daily at the University of Chicago, where he has been teaching since 1935. Dr. Kirsner served as an Army surgeon in Europe and the Pacific during World War II. Dr. Kirsner is recognized internationally as one of the leading figures in the modern development of the field of gastrointestinal medicine.

Dr. Koch received his medical degree at the University of Chicago – where he studied under Dr. Kirsner – and completed his training in gastroenterology at the Mayo Clinic in Rochester, MN. He is a professor of medicine at the Georgetown University School of Medicine, and his special interests involve micronutrients and anti-oxidants in gastrointestinal disorders. He is the author of more than a hundred scientific papers, presentations, and book chapters in his field, and was kind enough to answer some of my questions to cast further lights upon his research and conclusions.

“My interest in the Helicobacter pylori stomach bacterium was raised when I had a chance to meet with Dr. Barry Marshall from Australia,” Dr. Koch told me. “He discovered this organism by culturing the germ from patients with peptic ulcers; then he swallowed it in his attempt to show its importance in formation of peptic ulcers.” In doing so, Marshall reversed decades of medical doctrine which held that ulcers were caused by stress, spicy foods, and too much acid; he received the Nobel Prize in Medicine in 2005 in recognition of his research.

According to Dr. Koch, his paper on Jackson arose from his interest in whether “history repeats itself.” “Many individuals seen for upper intestinal problems at the Clarksburg, WV, Veteran’s Administration (VA) hospital after Persian Gulf War exposure were found to have the H. pylori organism,” Dr. Koch said. “Thomas Jackson still has family members living there and H. pylori infection is a common diagnosis in the area.” He added that published studies suggest that West Virginia may have one of the highest rates of infection in the country.

“Since Thomas Jackson grew up in Clarksburg, it is likely that he was exposed to the H. pylori bacterium,” Dr. Koch told me. When he visited the Stonewall Jackson Shrine off of Interstate 95, south of Fredericksburg, VA, Dr. Koch saw that the “official” explanation – as described at the Shrine - is that Jackson died essentially of an abscess adjacent to the lung caused by a fall from his horse “Little Sorrel.” “His symptoms and clinical course are not consistent with this diagnosis and certainly many other authors have already stated this point,” he added.

Dr. Koch noted that Stonewall Jackson’s personal surgeon – Dr. Hunter Holmes McGuire – was "not just another country doctor." Indeed, McGuire is a founding father of modern medicine in the state of Virginia and the VA medical center in Richmond, VA, is named after him. Still, Dr. Koch wanted to know more about McGuire’s major professional interests, so he and his daughter, Kristina, obtained reader passes from the Library of Congress.

“You can imagine our excitement when we found that the Rare Books Collection at the library contains a short textbook written by Dr. McGuire after the Civil War,” Dr. Koch told me. “The book was brought up in an elevator from the deep vault by a librarian. When we carefully examined the book, we found that Dr. McGuire's main medical interest is in the field of death rates caused by open abdominal wounds compared to closed abdominal wound, in other words gunshot or stabbing wounds (open) as opposed to perforations of the intestine or ulcers,” he added.

Dr. Koch noted that there was minimal specialization in gastroenterology at that time, but peptic ulcers were identified by autopsy in the 1850’s, well before the onset of the Civil War. “It seems unlikely that Dr. McGuire ignored the potential diagnosis of a closed abdominal wound in Stonewall Jackson,” he told me, but, absent accepted surgical remedies, there was not much McGuire could do to intervene.

Dr. Koch said that gastric disease is an ongoing concern for soldiers deployed around the world today. “Our ongoing concern is that individuals can bleed from peptic ulcer disease without any advanced symptoms as a warning,” he told me. Drugs – such as ibuprofen – are routinely taken for “aches and pains,” but they also have risks of stomach ulcers which could present as a massive internal bleeding.

“Out in the field, it is likely that many soldiers are using these medicines and are not aware of the risks of taking these drugs,” Dr. Koch said. The doctors also propose that military personnel who have lived in a region with a high prevalence of H. pylori should be routinely tested before they are deployed.

The article has very interesting details on Jackson’s early bouts with gastric disease and a spirited defense of the doctors’ hypothesis on the disease’s implications following Jackson’s wounding at Chancellorsville. The story of Dr. Marshall is further witness to the fact that medical theories change with time and new evidence. The doctors round out the article with some good advice for today’s military.

For Dr. Koch, the most interesting aspect of this story is that it remains difficult for us to learn from historical lessons. As his hypothesis strays farthest from the “conventional wisdom” of what ultimately killed “Stonewall” Jackson, it might seem that he has a greater burden of proof. Still, Dr. Koch made a very good point in telling me, “Why would we not think that we could suffer health problems similar to those of our distant relatives?”

1 comment:

Unknown said...

I find all of these theories fascinating. Although many a doctor and historian has speculated on Jackson's death, we will unfortunately never know the truth.