Stonewall Jackson’s “Pleuro-Pneumonia”

On this day in 1863, General Thomas J. “Stonewall” Jackson, one of the wiliest military commanders this country ever produced, died eight days after being shot by his own men. He had lost a massive amount of blood before having his left arm amputated by Dr. Hunter Holmes McGuire, arguably the most celebrated Civil War surgeon of either side. Initially, Jackson seemed to be recovering satisfactorily, but then deteriorated progressively with recurrent right-sided chest pain, difficulty breathing, and mounting fatigue. McGuire maintained that post-operative “pleuro-pneumonia” was the disorder that carried him off, a diagnosis that has since been the most widely accepted explanation for Jackson’s death.

Dr. McGuire was a careful observer with vast experience in managing such cases. However, the summary of Jackson’s fatal illness, which he published in the Richmond Medical Journal in 1866, makes no mention of the two cardinal features of fulminant pneumonia: fever and productive cough. If that account is accurate, and Jackson exhibited neither fever nor productive cough during his fatal illness, then recurrent pulmonary emboli, rather than pneumonia, would be the post-operative complication most likely responsible for his death.

Pulmonary emboli are blood clots generally originating in the legs, which dislodge and migrate via the veins to the lungs, where they come to rest in the pulmonary arteries. They create “difficulty breathing” of the kind Jackson experienced by destroying areas of the lung fed by the arteries in which they lodge and by inhibiting oxygenation of blood by a variety of other mechanisms. Jackson likely sustained his first pulmonary embolus at 10 a.m. on Sunday, 3 May 1863, approximately eight hours after having had his arm amputated, when he first complained of pain in his right chest accentuated by breathing. His risk of developing such blood clots would have been extremely high then. Aside from major trauma, which has been shown to render the blood hypercoagulable, age, need for surgery or blood transfusion, the presence of fractures and spinal cord injuries each has been shown to be an important risk factor for deep vein thrombosis in trauma patients. Jackson had several of these. He was also bedridden post-operatively, yet another important risk factor. During strict bed rest, blood tends to stagnate and clot in leg veins, because the pumping action of muscles responsible for propelling blood through these veins is markedly reduced during immobilization.

By the sixth post-operative day, Jackson was no longer having chest pain. However, his breathing was extremely labored, and he complained of total exhaustion. If he was having recurrent pulmonary emboli, as McGuire’s summary of his case suggests, he had by then reached a tipping point with respect to his pulmonary function. As the number of emboli increased, damage accumulated to such an extent that Jackson’s lungs were no longer able to oxygenate his blood sufficiently to sustain life, and his spirit “passed from earth to the God who gave it.”

Featured Image: The death of Stonewall Jackson by Currier & Ives. Public Domain via Wikimedia Commons.