Stonewall Jackson and the “Old Man’s Friend”

When Stonewall Jackson died on May 10, 1863, his attending physicians attributed the death to a pneumonia Jackson had developed four days after amputation of his arm. The infection was believed to be secondary to a pulmonary contusion, or bruised lung, that Jackson may have suffered after falling from a stretcher during his removal from the field.  For nearly 150 years, that diagnosis was largely unchallenged. More recently, however, modern physicians have begun offering alternate possibilities for his cause of death.

The most commonly suggested alternative is pyemia, or blood poisoning. Known today as sepsis, pyemia was a well-recognized and deadly condition during the pre-antibiotic days of the Civil War. To assert, however, that Jackson died of pyemia instead of pneumonia implies that the two conditions are distinctly separate – a circumstance that was often untrue during the 19^th century.

To the Civil War physician, pyemia was viewed as a surgical complication, and its presence was often heralded by changes at the wound site: a watery, foul-smelling discharge followed by sloughing and separation of the closed incision. By contrast, pneumonia was considered an inflammation of the lungs that would lead to death through then unknown mechanisms.

Today, we understand that septicemia is actually a systemic response to the presence of pathologic microorganisms in the bloodstream. As such, the organisms must have a source from which to enter the circulation. Either pneumonia or a contaminated wound – along with numerous other conditions – can serve as the focus of the infection.

Pathologically speaking, Stonewall Jackson did succumb to a septic condition. But what was the source of his sepsis: pneumonia or his surgical site? His physician, Hunter Holmes McGuire, repeatedly documented in post-war writings that Jackson’s amputation site never showed the tell-tale signs of pyemia. McGuire and four other physicians, however, did find evidence of Jackson having pneumonia.

In the 1800s, before the advent of antibiotics, pneumonia was often a deadly disease. Dr. William Osler, one of the founders of the Johns Hopkins School of Medicine, wrote in the 1898 edition of his textbook The Principles and Practice of Medicine that pneumonia was “the most fatal of all acute diseases.” Nonetheless, at the time, pneumonia was regarded as one of the most peaceful ways to die. So much in fact that Osler’s description of the process led to the disease being commonly referred to as “the old man’s friend.”

Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those ‘cold gradations of decay’ so distressing to himself and his friends.

– Sir William Osler (1898)

Jackson’s course of illness – prostration, “muttering delirium,” drowsiness, and semi-consciousness – is consistent with descriptions of fatal pneumonia as documented in The Medical and Surgical History of the War of the Rebellion, a compilation of Union and Confederate medical reports published in the post-war years of 1870-1888. Conversely, a thorough review of the primary source descriptions of Jackson’s death reveals findings less consistent with sepsis from a wound infection.

Although Stonewall Jackson was only 39 years old when he died, his body had been weakened by an unfortunate series of events: an upper respiratory infection, three bullet wounds, a significant loss of blood, being dropped from a stretcher, amputation of his arm, and several days of a febrile illness.  His peaceful “cross over the river” is most consistent with 19^th century medical descriptions of septic pneumonia or “the old man’s friend.”