Hektoen International

A Journal of Medical Humanities

The imponderable ‘what-ifs’: did the medical issues of three Confederate generals cause the South to lose the war?

Kevin R. Loughlin 


Winfield Scott’s “Anaconda Plan,” 1861
J.B. Elliott
Library of Congress

During the darkest days of World War II, Winston Churchill was credited as saying, “The imponderable ‘what- ifs’ accumulate”. Throughout history, imponderable what ifs have provoked the observer to consider how historical outcomes may have turned out differently. Such it is with the Civil War. It can be reasonably argued that the deaths of Albert Sidney Johnston and Stonewall Jackson and the illness of Robert E. Lee at Gettysburg irrevocably altered the course of the conflict and significantly contributed to the ultimate outcome.

At the outset of the Civil War both the North and South had strategic plans. The estimable Winfield Scott proposed the “Anaconda Plan” for the North, which would start by blockading the seacoast, then drive down the Mississippi to weaken the Confederacy to the west, and conclude with an attack through the heart of the Confederacy.

The South also had plans. Jefferson Davis favored a defensive strategy. He postulated  that a war of attrition would frustrate the better equipped Union and ultimately result in an armistice with the South and subsequent secession. An alternative Confederate strategy proposed by P.G.T. Beauregard was to attack in the western theatre and to control the river routes, first the Tennessee and Cumberland rivers and, if successful, then the Mississippi. On the eastern front, they would aim to capture Washington D.C. for both strategic and psychological proposes and then move northward into Maryland and Pennsylvania.

Albert Sidney Johnston graduated from West Point in 1826. He gained his early experience in the Texas War of Independence and the Mexican-American war. At the start of the Civil War, he was considered among the most gifted of the young generals, and Jefferson Davis placed him in charge of the Western Campaign.

Before, the battles of Fort Henry and Fort Donelson, Johnston had urged that the forts be fortified and additional  troops be assigned to their defense. However, his pleas were ignored, and Grant captured both forts in February of 1862 which delivered control of the Tennessee and Cumberland rivers to the Union. The control of these rivers emboldened the Union to move forward toward Shiloh to complete the larger goal of dominance of the western theatre.

The armies led by Johnston and Grant collided at Shiloh, Tennessee on April 6, 1862. In retrospect, this battle, more than either New Orleans or Vicksburg,  ultimately guaranteed Union control of the western theatre and the Mississippi.

Albert Sidney Johnston had repeatedly demonstrated personal valor during battle. His valor was at its zenith at Shiloh. Like many Confederate generals, he personally led the attack. On the first day of battle at the salient, Johnston was hit below the knee, probably by friendly fire, which severed his popliteal artery. At first he did not recognize the gravity of the wound, perhaps because of nerve damage that he had suffered to the same region during a duel in 1937. However, the severity of the wound quickly became clear as the blood filled his boot. The consequences of the loss of a leader like Johnston did not go unrecognized. His death was a strong blow to the Confederacy. Jefferson Davis believed that the loss of Johnston “was the turning point of our fate”. Davis would further state “Without doing injustice to the living, it may safely be asserted that our loss is irreparable; and that among the shinning host of the great and good who now cluster around the banner of our country, there exists no purer spirit, no more heroic soul, than that of the illustrious man whose death I join you in lamenting.” One can only speculate that if Johnston had survived, the South would have prevailed in the western theatre which would have caused the Union to wage war on two fronts. Such an obligation would have compromised their presence in Virginia, Maryland, and Pennsylavania.

Throughout American military history, few figures have attained the stature of Thomas J. “Stonewall” Jackson. He was born in 1824 in what is now West Virginia. He was poorly prepared academically for West Point and struggled at first, but demonstrating the resolve, hard work and determination that would be the signature of his military career, he graduated 17th out of 59 students in the class of 1846. Two of his classmates were George Pickett and George MCClellan.

Jackson served in the Mexican War and taught at the Virginia Military Institute. In 1861, when the Civil War broke out, he was put in command of several Virginia Infantry regiments by the governor of Virginia. He distinguished himself in the Battle of First Manassas where he received his nickname. This occurred when General Bernard Bee, in the midst of encouraging his men to fight on, pointed at Jackson and shouted, “Look, men, there is Jackson standing like a stone wall!” He would later be a major force at Second Manassas, Antietam, and Fredericksburg, during which he led the Second Corps of the Army of Northern Virginia under Robert E. Lee. Jackson was known for his audacity and tactical judgment in battle.

He next saw action at Chancellorsville on May 2, 1863. While returning to camp  from personal reconnaissance of  the Yankee front line, he was shot by friendly fire, twice in the left arm and once in the right hand. Members of the 18th Northern Carolina Regiment mistakenly took him for an advance party of the enemy and opened fire. As the shots occurred at dusk, he did not receive immediate medical attention and reportedly was accidentally dropped from  his stretcher twice. His left arm was seriously damaged and the next day was amputated by Hunter Holmes McGuire. Jackson lingered and died eight days later, on May 10, 1863. It has been speculated that he died of either pneumonia or pulmonary embolus, and the scenario and time frame would fit with either diagnosis, although sepsis has also been considered. Lee was devastated when informed of Jackson’s death and said, “I’m bleeding at my heart”.  Lee considered the loss of Jackson so significant that he restructured his high command. Before his death Jackson commanded the 2nd Corps of the Army of Northern Virginia and Longstreet commanded the First. However, after Stonewall’s death, Lee split the 2nd Corps in two. The original 2nd Corps was to be led by Richard S. Ewell, also known as “Old Bald Head”, and the  3rd Corps was led by Ambrose P. Hill. Longstreet remained leader of the First Corps. Neither Ewell or Hill had the battlefield boldness or judgment of Jackson, and their shortcomings contributed to the outcome at Gettysburg.

Robert E. Lee occupies a secure position in the pantheon of great modern military leaders. Historians concur that his military genius was evident throughout the war, except at Gettysburg. It has long been a point of historical interest, as to what was the cause of Lee’s apparent aberration as a strategist and tactician at Gettysburg, following so closely on the heels of his brilliant campaigns at Fredericksburg and Chancellorsville. Yes, there were factors that contributed to the defeat there other than Lee’s generalship. Certainly, the absence of his trusted cavalryman Jeb Stuart until late on July 2, 1863 was a critical element that deprived Lee of essential reconnaissance.

Lee was in apparent good health until March 1863 while when camped near the Rappahannock River, he developed sharp chest pain with radiation to his arms. His physicians diagnosed an “inflammation of the heart sac” and confined him to bed. Given the state of medical knowledge at the time, no other treatment was initiated and he apparently recovered. However, several historians have posited that heart disease, which was the cause of Lee’s death in 1870, played an important role in his performance at Gettysburg. Angina and pericarditis have both been proposed as contributing elements to what has been considered Lee’s poor strategy, particularly on July 2nd. Why was Pickett’s charge not initiated on July 2nd to reinforce Barksdale’s charge, which appeared to be heading to break through the Union lines, rather than waiting to give Pickett the order for the ill-fated offensive on July 3rd?  This question has never been adequately answered. Lee’s apparent strategic indecisiveness on the battlefield in Pennsylvania has never been satisfactorily explained, but clearly it was the seminal event that began the South’s demise.

What if Johnston had not been killed at Shiloh? What if he had survived and helped carry out Beauregard’s proposal to attack the Union’s center in Ohio in late 1862? What  if he had been available to Lee at Gettysburg? What if Stonewall Jackson had lived to lead the 2nd Corps at Gettysburg and to support Barksdale’s change on July 2, 1863 or Pickett’s on July 3rd? What if Lee had not been distracted at Gettysburg by chest pain? What if the Confederates had prevailed at Gettysburg? What if a defeat at Gettysburg compelled the North to call an armistice and leave Southern secession in place? The answer to these questions remain unanswered. History’s only reply is silence. The imponderable ‘what- ifs’ indeed accumulate.



KEVIN R. LOUGHLIN, MD, MBA is a urologic surgeon at Brigham and Women’s Hospital in Boston and a professor of surgery at Harvard Medical School. He completed his undergraduate education at Princeton University and received his MD from New York Medical College.He also holds an MBA from Boston University and an MA(Hon) from Harvard. He is a trustee of the American Board of Urology and is a member of the board of directors of the American Urological Association and the American Association of Clinical Urologists. He is an omnivorous reader and particularly enjoys military history. He enjoys running, biking, and playing with his dogs, Finn and Lizzie.


Highlighted in Frontispiece Summer 2014 – Volume 6, Issue 3
Summer 2014  |  Sections  |  War & Veterans

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