MILITARY MEDICINE, 177, 3:315, 2012

Early Onset Pneumonia Following Pulmonary Contusion:

The Case of Stonewall Jackson
Mathew W. Lively, DO

ABSTRACT Confederate Lieutenant General Thomas J. “Stonewall” Jackson was wounded by his own men at the
Battle of Chancellorsville during the American Civil War. While being removed from the field, Jackson fell from the
litter and struck the right side of his chest on a large stone or stump. Four days following the amputation of his left arm,

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Jackson developed pneumonia in his right lung. His treating physicians believed the infection developed secondary to a
pulmonary contusion that occurred when he fell from the litter. Pulmonary contusions are an independent risk factor in
the development of post-traumatic pneumonia and an infection that occurs within 72 to 96 hours of injury is termed an
early onset pneumonia. The nature and timing of Stonewall Jackson’s illness following his wounding is consistent with
the modern diagnosis of early onset pneumonia following chest trauma.

INTRODUCTION the field was complicated by a shoulder-height fall from a

Thomas J. “Stonewall” Jackson was an 1846 graduate of the
United States Military Academy and served with distinction
as an artillery officer in the Mexican–American War. Follow-
ing the war, he became an instructor at the Virginia Military
Institute and subsequently enlisted in the Confederate States
Army at the outbreak of the American Civil War. Recognized
for his aggressive style and an ability to move his forces
rapidly over long distances, Jackson was promoted to lieu-
tenant general and was serving as a corps commander at the
time of his wounding and death in May 1863.
Although the definitive cause of Jackson’s death following
his wounding is unknown, five physicians treating him at the
time agreed it was the result of a pneumonia that developed
during his recovery. Modern reviewers of the case have offered
alternate possibilities,1–5 but a recent review of the avail-
able evidence supports the original diagnosis of pneumonia.6
Jackson’s physicians believed the infection had developed sec-
ondary to a pulmonary contusion that occurred when the gen-
eral fell from a stretcher while being removed from the field. If
so, his case would be consistent with the diagnosis of early
onset pneumonia (EOP) following chest trauma.
CASE REPORT
On the night of May 2, 1863, during the Battle of
Chancellorsville, Confederate Lieutenant General Thomas J.
“Stonewall” Jackson was shot by his own infantry after he and
members of his staff were mistaken for enemy cavalry while
returning to the line following a reconnaissance. Jackson
received one bullet wound in the right palm and two in the left
arm. One bullet shattered the left upper humerus three inches
below the shoulder joint and damaged the brachial artery.
Jackson lost a large amount of blood as his removal from
Department of Internal Medicine, West Virginia University, 1 Medical
Center Drive, Morgantown, WV 26506.
litter when one of the bearers tripped while walking through
the woods.
Five hours after the trauma, Jackson’s initial shock had
stabilized adequately to proceed with surgery. Hunter Holmes
McGuire, MD, the corps medical director, performed a circu-
lar operation of the upper left humerus without complication
and with minimal blood loss. Seven hours after surgery,
Jackson complained of right side pain and stated he struck
the area on a stone or a stump during his fall from the litter
the previous night. McGuire’s examination at the time
revealed “the skin was not bruised or broken and the lung
performed as far as I could tell, its proper function.”7 By
evening the pain had resolved and Jackson rested comfortably.
Two days following surgery, McGuire changed the surgical
dressing and noted the wounds were healing well, writing:
“union by the first intention had taken place to some extent in
the stump, and the rest of the surface of the wound exposed
was covered with healthy granulations.”7 Jackson’s only
complaint during this time was a slight annoyance from an
upper respiratory infection he had developed the day before
his wounding.
In the early morning hours of the fourth postoperative day,
Jackson awakened with nausea followed by severe right side
pain and difficulty breathing. Upon examining the chest,
McGuire discovered “pleuro-pneumonia of the right side.”7
Despite treatment with morphine, Jackson continued to suffer
throughout the day with chest pain accompanied by fever,
restlessness, and intermittent delirium. The chest pain improved
the following day but Jackson continued to show signs of
increasing “prostration” and dyspnea. Dressing changes on
this day revealed the operative site continuing to heal well
without complications.
Throughout the sixth postoperative day, Jackson continued
to weaken with fever, restlessness, and altered mental
status. He lapsed into a semiconscious state the next
afternoon and died on May 10, 1863, 7 days following
his amputation.

MILITARY MEDICINE, Vol. 177, March 2012 315

 Case Report
Pneumonia and Chest Trauma
Compression, shearing, and blast are the three types of
blunt force that can lead to thoracic injury.8 A pulmonary
contusion often occurs when compression of the bony and
cartilaginous chest structures results in mechanical tearing of
the underlying lung tissue.9 A contusion injury to the paren-
chyma can trigger an intense inflammatory response charac-
terized by leukocyte recruitment, macrophage activation, and
initiation of complement and coagulation cascades.10 This
inflammatory response, in turn, can lead to alveolar edema,
surfactant dysfunction, and decreased lung compliance.10 Ani-
mal models of pulmonary contusion have shown deficits in
surfactant activity and lung atelectasis can be pronounced
within 24 hours of trauma.10 The severity of the pathophysio-
logic changes depends on the extent of injury as contusions
involving greater than 18% of lung volume carry a signifi-
cantly higher mortality than those comprising a smaller area
of involvement.11
It is not unusual for direct chest trauma to result in a
pulmonary contusion without associated rib fractures or other
evidence of injury. Historically, the first known description of
pulmonary damage without an associated chest wall injury
dates to 1761.9 Pulmonary contusions without signs of outward
trauma were recorded throughout the Civil War and those with
an associated “traumatic pneumonia” had a mortality rate as
high as 85%.12 Investigations of explosive blast injuries during
subsequent wars also demonstrated pulmonary contusions
occurring as a result of pressure wave impacts on the chest
wall.9 Trauma studies have failed to show a correlation
between rib fractures and pulmonary contusions,8,13 whereas
case reports in athletes document pulmonary contusions with-
out associated fractures or external evidence of injury.14–16
Period medical texts also identified pneumonia as a com-
plication of pulmonary contusions. For example, in his text-
book “The Principles and Practice of Medicine,” Sir William
Osler referred to the condition as “contusion-pneumonia.”17
Dr. Hunter Holmes McGuire believed Jackson suffered a
pulmonary contusion when falling from the litter, writing
in 1866: “Contusion of the lung, with extravasation of blood
in his chest, was probably produced by the fall referred
to, and shock and loss of blood prevented any ill effects until
reaction had been well established, and then inflamma-
tion ensued.”7
Today, the term EOP is used to describe a pulmonary
infection that develops within 72 to 96 hours of hospital
admission following trauma.18,19 Modern studies have estab-
lished pulmonary contusions as an independent risk factor in
the development of EOP.8,18,19 Animal models have also
shown that arterial hemorrhage in the presence of a pulmo-
nary contusion markedly decreases bacterial clearance in the
contused lung.20 The occurrence of pneumonia in trauma
patients may promote the onset of multisystem organ fail-
ure18,21 and Antonelli et al19 documented 38% of trauma
patients with EOP developed sepsis syndrome secondary to
the pulmonary infection.
316
DISCUSSION
In the case of Stonewall Jackson, he first complained of pain
in his right chest within 12 hours of being dropped from the
litter. Jackson attributed the pain to his striking the area
against a stone or stump during the fall, a trauma that could
easily have caused a pulmonary contusion. McGuire exam-
ined the chest but found no signs of injury or pulmonary
dysfunction. Four days following the fall, Jackson was found
by physical examination to have developed pneumonia in the
same segment of lung in which he first complained of pain.
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Appearance of the lung infection 4 days following the direct
trauma would be consistent with the modern diagnosis of
EOP. Additionally, Jackson had suffered an arterial hemor-
rhage as a result of the gunshot wound, possibly contributing
to the development of pneumonia in the contused lung, and
he subsequently died of a septic condition, an event also con-
sistent with the sequela of EOP.
The possibility exists that Jackson did not have a pulmo-
nary contusion and instead developed a standard postopera-
tive pneumonia related to atelectasis. Modern data suggest the
incidence of such pulmonary complications is more frequent
with thoracic and abdominal procedures as opposed to ortho-
pedic surgeries.22 The incidence of postoperative atelectasis
and pneumonia in patients undergoing surgery outside of
pleural or peritoneal cavity is reported to be 1%.22 Jackson’s
only two procedures were an amputation of the left humerus
and extraction of a bullet from the palm of the right hand.
Although some modern reviewers of the case have also
proposed pulmonary embolus or wound sepsis as potential
causes of Jackson’s death,1–4 his slow course of illness and
lack of suppurative changes at the surgical site decrease the
probability of these conditions being the cause of his death.6
In conclusion, Stonewall Jackson likely died from pneu-
monia 1 week after undergoing amputation of his left arm.
The infection presented in an area of the chest that was
directly injured during a fall from a stretcher 4 days prior.
Jackson’s physicians at the time attributed his pneumonia to a
pulmonary contusion that occurred as a result of this trauma.
In modern medical terms, Jackson’s condition is consistent
with the diagnosis of EOP following chest trauma.
REFERENCES
1. Gorham LW: What was the cause of Stonewall Jackson’s death? Arch
Int Med 1963; 111: 540 –4.
2. Smith AD: Stonewall Jackson and his surgeon, Hunter McGuire. Bull
N Y Acad Med 1973; 49: 594– 609.
3. Haines JD: What killed Stonewall Jackson. J Okla State Med Assoc
1998; 91: 162–65.
4. Rozear MP, Greenfield JC: Let us cross over the river: the final illness
of Stonewall Jackson. VA Mag Hist Biogr 1995; 103: 29–46.
5. Koch TR, Kirsner JB: Chronic gastrointestinal symptoms of Thomas
“Stonewall” Jackson following Mexican-American war exposure: a med-
ical hypothesis. Mil Med 2007; 172: 6– 8.
6. Lively MW: Stonewall Jackson (1824–63) and the “Old Man’s Friend.”
J Med Biogr 2011; 19: 84– 8.
MILITARY MEDICINE, Vol. 177, March 2012
 Case Report
7. McGuire HH: Last wound of the late Gen. Jackson (Stonewall)—The
amputation of the arm–His last moments and death. Richmond Med
J 1866; 1: 403–12.
8. Wanek S, Mayberry JC: Blunt thoracic trauma: flail chest, pulmonary
contusion, and blast injury. Crit Care Clin 2004; 20: 71–81.
9. Cohn SM, DuBose JJ: Pulmonary contusion: an update on recent
advances in clinical management. World J Surg 2010; 34: 1959–70.
10. Raghavendran K, Notter RH, Davidson BA, Helinski JD, Kunkel SL,
Knight PR: Lung contusion: inflammatory mechanisms and interaction
with other injuries. Shock 2009; 32: 123–30.
11. Deunk J, Poels TC, Brink M, et al: The clinical outcome of occult
pulmonary contusion on multidetector-row computed tomography in
blunt trauma patients. J Trauma 2010; 68: 387–94.
12. Otis GA: Medical and Surgical History of the War of the Rebellion,
Part I, Vol. II, Washington, DC, Government Printing Office, 1870.
13. Pape HC, Remmers D, Rice J, Ebisch M, Krettek C, Tscherne H:
Appraisal of early evaluation of blunt chest trauma: development of
a standardized scoring system for initial clinical decision making.
J Trauma 2000; 49: 496–504.
MILITARY MEDICINE, Vol. 177, March 2012
14. Lively MW: Pulmonary contusion in a collegiate diver: a case report.
J Med Case Reports 2011; 5: 362.
15. Lively MW, Stone D: Pulmonary contusion in football players. Clin
J Sport Med 2006; 16: 177–8.
16. Meese MA, Sebastianelli WJ: Pulmonary contusion secondary to blunt
trauma in a collegiate football player. Clin J Sport Med 1997; 7: 309–10.
17. Osler W: The Principles and Practice of Medicine, Ed 3, pp 108–137.
New York, D. Appleton and Company, 1898.
18. Michelet P, Couret D, Bregeon F, et al: Early onset pneumonia in severe
chest trauma: a risk factor analysis. J Trauma 2010; 68: 395–400.
19. Antonelli M, Moro ML, Capelli O, et al: Risk factors for early onset
pneumonia in trauma patients. Chest 1994; 105: 224–8.
20. Richardson JD, Woods D, Johanson WG, Trinkle K: Lung bacterial
Downloaded from https://academic.oup.com/milmed/article-abstract/177/3/315/4283644 by guest on 02 October 2019
clearance following pulmonary contusion. Surgery 1979; 86: 730–5.
21. Ciesla DJ, Moore EE, Johnson JL, Burch JM, Cothren CC, Sauaia A:
The role of the lung in postinjury multiple organ failure. Surgery 2005;
138: 749–58.
22. Brooks-Brunn JA: Postoperative atelectasis and pneumonia. Heart Lung
1995; 24: 94–115.
317