Historical Implications of a Failing Heart

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Robert E. Lee’s Medical History in Context of Heart Disease, Medical Education and the Practice of Medicine in the Nineteenth Century

Richard A. Reinhart, MD, FACC, FACP

Originally published in 2016 in the Surgeon’s Call, Volume 21, No. 1

Robert E. Lee, a well-known historical figure, was born in Virginia, and served in Virginia the majority of his professional career, both as a soldier and university president; his life and career is the subject of public history, as well as a subject of historical scholars. Scholars of the American Civil War are familiar with Lee’s military and personal history. During the past one and a half centuries, thousands of books, essays, and articles have chronicled Lee’s life. The realm of public history contains much about Lee. Writers stylize Lee as a heroic figure, an ideal father and husband, and selfless citizen; the public generally considered Lee to be in good health with a vigorous constitution. The historiography of Lee’s medical condition consists of reports detailing some specific aspects of his health, such as his final illness. The report and interpretation of his final illness varies from a contemporary report by his attending physicians at the time of Lee’s death[1] to a more recent interpretation ascribing his final illness to a stroke.[2] Authors of these previous reports have not written them in the context of the state of medical knowledge, medical practice, medical practitioners; and in the context of the state of medical education in the nineteenth century. Additionally, there has not been a comprehensive report chronologically detailing Lee’s illness.

During Lee’s 63 years (1807-1870), medical education and practice were in significant transition. Early in the nineteenth century, medicine was domestic, family centered, and typically a woman family member provided medical treatment to her own family; the practitioner of medical care at times branched out to other members of the local community. Subsequently, medical care transitioned to lay practitioners who provided care to the community; the role of healer gradually shifted from women to men, and only later in the nineteenth century were women more fully a part of the medical profession. Professionalization of American medicine did not begin to take place until later in the nineteenth century. Medical education in the late eighteenth century and early nineteenth century consisted of apprenticeships under the tutelage of established practitioners; little or no didactic instruction was available. Some early colonial physicians traveled to Europe for formal training, returning to the colonies to provide medical care and tutelage in the form of apprenticeships.

As medicine became professionalized, medical education, licensing, and practice became more structured. Nevertheless, during the Jacksonian period of the nineteenth century, the social and political climate of egalitarianism was unfavorable to the transformation of physicians to elite status, but rather was conducive to the development of medical sects and the existence of “quacks.” Medical sectarianism developed in competition to “regular” or “heroic” medicine, which was characterized by bloodletting, purging with calomel, and the utilization of tartar emetics. The era of scientific advances in the mid to late nineteenth century led to the predominance of “regular” practitioners and the decline of medical sects.

Figure 1. Robert E. Lee in 1865. Courtesy of the Library of Congress

Robert E. Lee in 1865.
Courtesy of the Library of Congress

Physicians progressed from just listening to patients give accounts of their symptoms to actual examination of the patient using auscultation and percussion. Medical instruments – stethoscope, thermometer, microscope, among others – began to enter the realm of the practitioner. Medical education became more standardized and scientifically based. Robert E. Lee lived during this transitional period in medical history; he had the opportunity to choose from a broad range of medical practitioners: the lay practitioner, the uneducated regular or sectarian doctor, and the educated/licensed regular physician. As we will see, Lee chose wisely for himself and his army.

Lee described in detail his symptoms as well as his physician consultations; he was not hesitant to describe his symptoms and disabilities to his family, friends, and at times to colleagues. Some of Lee’s physicians have left written accounts of their treatment of Lee. Family, friends and colleagues comment on Lee’s physical appearance and physical capacities. Nevertheless, historians have not produced reports that detail chronological correlations among Lee’s disabilities, the state of medical practice, and significant historical events.

In this essay, I review details of the state of medical knowledge, specifically heart disease, the practice of medicine, and medical education during Lee’s lifetime in the nineteenth century; this provides a background for a better understanding of Lee’s illness. The historiography of medicine and of Lee is familiar to scholars and public historians and reported in piecemeal; hence, in this essay I provide a detailed chronologic description of Lee’s illness and death and correlate this with the chronologic progression of medical knowledge and medical practice during his lifetime. This correlation provides for better understanding of Lee’s illness; additionally, this information, when placed in context of the modern practice of cardiology, provides additional understanding of Lee’s illness and death.

Finally, it is important to consider the historical implications of Lee’s illness. Given the timing of the exacerbation of Lee’s illness during periods of historical events, the course of history may have been different were he not to have had a failing heart; this issue is not addressed in this essay, but warrants future study.

In the nineteenth century, cardiology as a specialty did not exist; knowledge of heart disease was on a rudimentary level. Specialists were just beginning to emerge in medical practice. Practitioners considered chest pain equivalent to inflammation around the heart, related to rheumatism or pericarditis. Physicians did not make a connection between disease of the coronary arteries and heart attack. Austin Flint, a physician recognized as an expert in heart disease, did not make a connection between the chest pain of angina pectoris and coronary heart disease. Physicians recognized abnormalities of the heart valves as causative factors in heart disease because of the gross, recognizable nature of the valve lesions; these gross valvular abnormalities were associated with cardiac enlargement noted at the time of autopsy in patients who died with symptoms associated with heart disease.

Austin Flint Courtesy of the National Library of Medicine

Austin Flint Courtesy of the National Library of Medicine

Armamentarium available for diagnosis of heart disease was limited. The modern binaural stethoscope was just coming into use by physicians.[3] Physicians did not measure blood pressure in the clinical setting and therefore, hypertension as a clinical entity was not yet recognized.[4] Physicians noted in detail examination of the pulse, with description of characteristics related to strength, rate, and rhythm, based on palpation of a peripheral artery.[5] Body temperature was not routinely measured using a thermometer, but rather was surmised by the general appearance of the patient.[6]

Practitioners directed treatment of heart disease at the symptoms; a monistic approach to disease prevailed; the recognition of organ-related pathology was just emerging. Treatment varied based on the physician’s training and medical beliefs. In the middle to late nineteenth century, the period of Lee’s illness, there existed various schools of thought for medical practitioners. The reason for this diversity of medical practice was the existence of multiple methods of physician training; hence, physicians employed various methods in the practice of medicine. The dissatisfaction with traditional medical beliefs created the substrate for the development of splinter groups or medical sects.[7]

During the American Civil War, the medical community learned a great deal about hygiene, communicable disease and its prevention, as well as trauma and its surgical treatment. They gained much of this medical knowledge due to the close proximity of soldiers living in crowded and squalid conditions. Military medical directors recognized hygiene, sanitary measures including waste treatment, vaccination for small pox, and surgical amputation as important factors in maintaining a relatively healthy, hence functional, army.[8] Germ theory was not yet widely recognized, although physicians reported some observations connecting germs to infection and a few years later described the beneficial use of antiseptic principles in the surgical setting was described.[9] There was little advance in the diagnosis and treatment of heart disease during this period.

HEART DISEASE IN THE NINETEENTH CENTURY

In the twenty-first century, physicians recognized the diagnostic importance of symptoms that a patient provided to be as accurate diagnostically as some of the more sophisticated testing procedures.[10] In the nineteenth century, physicians did not correlate between symptoms and pathology of the heart. Examination of the heart was limited to mensuration, inspection, palpation and auscultation; the use of the stethoscope for listening to heart sounds did not come in to common usage until the latter part of the nineteenth century.[11]

The post mortem examination was used to correlate physical signs with abnormal anatomy of the heart, lungs and great vessels.[12] During a patient’s life, there existed no tests or technology for establishing cardiac diagnoses. Electrocardiography and x-ray examination did not come into use until the late nineteenth or early twentieth century.[13] Basic testing such as blood pressure determination[14] and temperature measurement[15] was not in routine clinical use during this time.

In 1772, William Heberden first described in detail angina pectoris as a cause of chest pain; Heberden presented this lecture at the College of Physicians in London:

There is a disorder of the breast, marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare, of which I do not recollect any mention among medical authors. The seat of it, with which it is attended, may make it not improperly be called Angina pectoris…[patients] are seized, while they are walking, and more particularly when they walk soon after eating….After it has continued for some months, it will not cease so instantaneously upon standing still; and it will come on, not only when walking, but when they are lying down…though the natural tendency of this illness be to kill the patients suddenly….[however] this disorder will last, as I have known it more than once, near twenty years.[16]

Heberden did not make a connection between angina pectoris and coronary artery disease. Interestingly, Heberden’s description of angina pectoris matches the symptoms and clinical course experienced by Lee; today, physicians recognize these symptoms as being diagnostic of coronary artery disease.

In 1779, Caleb Hillier Parry reported a connection between angina pectoris and coronary artery disease; he presented his findings to a Medical Society in Glocestershire, England. Parry gave credit in his report to his colleague Edward Jenner, “It was generally admitted that many of the cases, which are vulgarly called asthma, originated, through different media, from diseases of that organ; and it was suggested by Dr. Jenner, that the Angina Pectoris arose from some morbid change in the structure of the heart, which change was probably ossification, or some similar disease, of the coronary arteries.”[17]

It was not until 1912 that James B. Herrick described the clinical features of sudden obstruction of the coronary arteries; he demonstrated that survival, rather than sudden death, could be the outcome. He pointed out, “…The prevalence of the view that this condition was almost always suddenly fatal….there are reasons for believing that even large branches of the coronary arteries may be occluded – at times acutely occluded – without sudden death, at least without death.” He proposed that, “The clinical manifestations of coronary obstruction will evidently vary greatly, depending on the size, location and number of vessels occluded….and by the ability of the remaining vessels properly to carry on their work.”[18] Lee’s clinical course followed this description, but the medical profession did not recognize this clinical connection until well after Lee’s death.

Austin Flint, a prominent physician with an interest in diseases of the heart, described angina pectoris in his textbooks in the late 1800s; however, he did not make the connection between angina pectoris and coronary artery disease. Flint stated, “The affection occurs oftener in connection with lesions seated in the aorta than elsewhere…Angina pectoris is a rare affection… Of over one hundred and fifty cases of organic heart disease of the heart, as evidenced either by the results of examination after death or well-marked physical signs, the histories of which are before me, this complication existed in seven only.”[19] Hence, manifestations of coronary artery disease were either rare or unrecognized. Flint did not describe the connection between angina pectoris and obstruction of the coronary arteries, despite reports of this connection existing in the previous century.

It is around this time in history, the mid to late nineteenth century, when Lee began to develop symptoms of heart disease. Lee wrote letters describing symptoms that were diagnostic of coronary artery disease; he made the connection of his symptoms later in life to symptoms he experienced at the onset of his illness in 1863. Lee’s physicians attributed the cause of his chest pain to rheumatism or pericarditis. Although Parry described the relationship of angina to coronary artery disease nearly a century before, coronary artery disease was felt to be rare and its relationship to angina and myocardial infarction was not described in textbooks of clinical medicine. Lee’s physicians never attributed the diagnosis of coronary artery disease his illness during his life.

During Lee’s adult life, medical education consisted of regular (allopathic) and irregular (sectarian) medical schools. There was a mix of university affiliated schools and proprietary regular schools subscribing to various standards of education. In addition to the regular medical schools, a variety of sectarian medical schools existed. This mix of medical education produced practitioners representing various cults, sects, and allopathic training. Additionally, regulatory measures, including licensing of practitioners, were limited and the cultural, social, and economic factors that influenced the practice of medicine existing during Lee’s lifetime likely had some impact on his medical outcome due to the slow progress of scientific discovery. 

NINETEENTH CENTURY MEDICAL INSTRUMENTS AND PHARMACY

Surgery provided the most pressing need for medical instruments during the Civil War.[20] Amputation of limbs was required when wounds became infected or unsalvageable. Debridement of infected tissue was standard practice. Germ theory and disinfection, although postulated by Ignaz Semmelweis as early as 1850, was not put into practice and did not lead to the use of sterile technique, or even hand washing, until after the Civil War.[21].Even when Semmelweis demonstrated that hand washing with chloride solution was effective in preventing puerperal fever, there was considerable disagreement and resistance to its use among physicians.[22]

Anesthesia for surgical procedures was in common use during the latter part of the nineteenth century and used routinely during the Civil War. In 1846, William T. G. Morton demonstrated ether as a general anesthetic; although Morton administered the ether, the operating surgeon published the report.[23]

As opposed to surgical instruments that were many, medical instruments were few: monaural or binaural stethoscope, microscope, ophthalmoscope, and thermometer; physicians used none of these routinely. It was not until the latter part of the nineteenth century that physical examination using percussion and auscultation of the heart and lungs came into use by physicians as a diagnostic method.[24] It was not until 1869 that Carl Reinhold August Wunderlich first published his findings on the study of body temperature, measured with a thermometer, and the relationship of temperature to disease.[25] The thermometer was cumbersome; the axilla used for measurement, took as long as 20 minutes to record, and read while still in the axilla. A thermometer was part of the surgeon’s medical kit during the Civil War, but the physician did not use it on a regular basis presumably because of its unwieldy nature.[26] There is no record of Lee having his temperature measured.

Civil War-era monaural stethoscope. From the collection of the NMCWM

Civil War-era monaural stethoscope. From the collection of the NMCWM

Cammann binaural stethoscope. c. 1870. From the collection of the NMCWM

Cammann binaural stethoscope. c. 1870. From the collection of the NMCWM

Measurement of blood pressure was not in widespread clinical use until the early twentieth century. In fact, practitioners did not accept the sphygmomanometer, the instrument in use today, until the early twentieth century. In 1905, an editorial in the British Medical Journal stated:

But it may be reasonably doubted whether instrumental research will ever be as useful in the investigation of blood-pressure in man as the fingers and ears of the cultivated observer. There is a certain risk that the multiplication of instruments tends to pauperize the senses and to weaken their clinical acuity; even the Sphygmograph is mainly used nowadays rather for the purpose of demonstration or of making a permanent record than for what it can tell us in diagnosis or prognosis.[27]

There is no record of the performance of blood pressure measurements on Lee.

In the middle of the nineteenth century, applying scientific principles to the use of pharmaceuticals was uncommon. There was a lack of understanding between an illness causing a patient’s symptoms and pathophysiology of the illness. A textbook of heart disease published in 1869, describes the treatment of angina pectoris along nonscientific lines; the treatment was a combination of heroic and botanical methods.[28]

Treatment outlined for angina pectoris in 1869 includes, “Stimulants and anodynes are indicated during the attack. Best will be Hoffmann’s anodyne, laudanum, Warner’s cordial, and brandy in moderate doses, repeated in short time if necessary; with mustard plasters over the chest between the shoulders and the warm foot-bath.”[29]

Flint recommended the following treatment for angina pectoris:

The severity of the pain during the attack, and its neuralgic character, point to the propriety of opium; and clinical experience shows that this remedy is more efficient than any other, in affording relief, and bringing the paroxysm to a close. It is to be given in doses proportionate to the amount of suffering, and repeated after short intervals if the objects be not obtained….Diffusible stimulants are to be given at short intervals. Brandy, or other kind of spirit, may be employed; also the ethereal preparations and the carbonate of ammonia. Revulsive applications which act quickly, are indicated, viz., sinapisms, dry cupping, vesication with strong aqua ammonia, hot fomentations, and stimulating pediluvia.[30]

In 1867, Lauder Brunton first described the use of amyl nitrite, a vasodilator, in angina pectoris.[31] Brunton noted the relationship between resolution of pain from angina and a flushing of the face along with a decline in arterial tension measured with sphygmographic tracings.[32] Nitroglycerine was first synthesized in 1846 and practitioners initially used it as a homeopathic remedy for headaches (like cures like);[33] only later, in 1879, reports showed it efficacious for angina.[34]

Aspirin was not available for clinical use during Lee’s lifetime. In 1899, Bayer pharmaceuticals first marketed aspirin for its anti-inflammatory action. The medical profession did not recognize the antiplatelet action and its beneficial effect in vascular disease of aspirin until the late twentieth century.[35] Therefore, during Lee’s lifetime there were no effective medicines in common use for angina pectoris. Some effective medications were just being discovered, but were not part of the physician’s armamentarium. Additionally, there were no medical instruments to aid in medical care except for the stethoscope, which was just coming into common use. Auscultation and percussion as a diagnostic aid was not fully developed and was not yet in common use.

I present Lee’s medical history with this backdrop of the level of understanding of heart disease, the diagnostic and therapeutic armamentarium available to treat heart disease, the diversity of medical practitioners and the cultural and economic influences on the practice of medicine.

The Medical History of Robert E. Lee

Robert Edward Lee was born  January 19, 1807; he died  October 12, 1870 at age 63, while serving as president of Washington College in Lexington, VA.[36] In between, he had a career as a military officer, first in the United States Army and subsequently in the Confederate States Army; this occupation was physically demanding for Lee, particularly in the later years of the Civil War. Those demanding years took a physical toll on Lee’s health; as his disease progressed, this was especially noticeable in his correspondence with his family, friends and comrades.

Writers portray Lee as a vigorous, healthy soldier able to withstand the rigors of military campaigns. With his army in the field actively engaged, Lee preferred to camp among his army rather than take advantage of offers from local residents to stay in their homes. Lee lived in his camp tent like his soldiers and, when his health permitted, he rode out on his horse Traveler to reconnoiter the battlefield.

Several earlier publications make up the historiography of Lee’s health.[37] The material for the following chronology of Lee’s health derives information predominantly from primary sources, or from a compilation of primary source material. Lee did not write an autobiography or memoir. His most objective biographer was Douglas Southall Freeman, who wrote a well-researched four-volume biography of Lee.[38]

Lee’s health and endurance was documented in the Mexican War on August 20, 1845 by his commanding officer, General Winfield Scott, who noted that, “[Lee] had been in the saddle continuously for 36 hours, had thrice crossed the pedegral. This constituted the greatest feat of physical and moral courage performed by any individual.”[39]

According to Freeman, Lee’s first and only illness prior to March 1863 was late in July of 1849, when he developed a protracted fever that probably was malaria, and was relieved of duty until the end of August.[40] However, Lee wrote in a previously unpublished letter to his friend, John MacKay, in September 1845, describing a febrile illness lasting several months, “I have been sick, sicker than I have ever been in my life. Early in Spring I had an attack or two of chills & fever … the Drs. got down one dose of medicine… [I] embarked for Boston with all my pills & powders packed in my trunk… was a well man just a fortnight ago…I brought back my medicines safe & intact…the Doctor was charmed with the efficacy of his doses & crows loudly upon my recovery…may he always have such patients.”[41]

In his personal life “…he loved good food—fried chicken, game, barbecued shoat, roast beef. In dealing with alcoholic beverages, his habits were abstemious lest he endanger his self-mastery. He had built up in this way, a dislike for tobacco, which he never used, and a hatred for whiskey. Even wine he drank rarely and in small quantities.”[42]

The onset of Lee’s cardiac illness is first noted in a letter to his wife  March 27, 1863, “The troops are not encamped near me & I have felt so unwell since my return [Lee arrived from Petersburg  March 19, 1863] as not to be able to go anywhere. I have been suffering from a heavy cold which I hope is passing away.”[43] Additional documentation related to the onset of his illness is noted, “He had not been sleeping well and he contracted a serious throat infection which settled into what seemed to be a pericarditis. His arm, chest and his back were attacked with sharp paroxysms of pain that suggest even the possibility of angina.”[44]

Lee moved from winter quarters to Mr. Yerby’s house under the care of the medical director of the army, Dr. Lafayette Guild. Guild became ill and Dr. S. M. Bemiss took his place. Lee’s illness kept him in bed for several days.[45] On April 9, 1863, at the onset of his illness, Lee proposed to the Secretary of War that the army cross into Maryland.[46]

On April 11, Lee’s illness began to abate somewhat. In a letter to his daughter Agnes he wrote, “I am able to ride out every day, & now that the weather has become good, I hope I shall recover my strength. My pulse is still about 90 the doctors say, too quick for an old man, but I hope the exercise and fresh air will reduce it soon.”[47] In subsequent weeks, in a letter to his wife on April 12, he initially states, “I am much better, my cough is not annoying, pulse declining, & I am free of pain.”[48] Subsequently, on April 19 in a letter to his wife he states, “I am feeble & worthless & can do but little.”[49] This waxing and waning of Lee’s symptoms is noted throughout the course of his illness; waxing and waning of symptoms is characteristic of the clinical course of coronary artery disease.

Lee won a victory over Hooker at Chancellorsville May 2-3, 1863; General Jackson was shot and subsequently died on  May 10. Lee began moving north with his army on  June 3. During his move northward to Gettysburg and during the Gettysburg campaign, Lee makes no mention in his correspondence of any symptoms related to illness. However, shortly after his withdrawal from Pennsylvania, his letters again reflect his manifestations of illness and debility. One infers that his symptoms between the end of March and the beginning of August, when he again began to write about his symptoms, that he was continuously ill, although Lee does not document this in his correspondence. Throughout his illness, when Lee is actively engaged in military action, typically he writes little or nothing about his physical symptoms.

Following Gettysburg, on July 4, 1863, Lee gave orders to begin the orderly march back to Virginia. On August 8, when back in camp in Virginia, Lee wrote to Davis asking that Davis replace him as commander of the Army of Northern Virginia:

I sensibly feel the growing failure of my bodily strength. I have not yet recovered from the attack I experienced last spring. I am becoming more and more incapable of exertion, and thus have been prevented from making the personal examinations and giving the personal supervision to the operations in the field which I feel to be necessary. I am so dull that in making use of the eyes of others I am frequently misled. Everything, therefore, points to the advantages to be derived from a new commander, and I more anxiously urge the matter upon Your Excellency from my belief that a younger and abler man than myself can readily be attained.[50]

Davis declined this request by Lee; a letter to Davis from Lee acknowledges this on  August 22, 1863.[51]

On September 4in a letter to his wife, Lee writes:

I am suffering ever since my last visit to Richmond from a heavy cold which resulted in an attack of rheumatism in my back, which has given me great pain & anxiety, for if I cannot get relief I do not see what is to become of me. I had at one time to go about a great deal & the motion of my horse was extremely painful, so much so that I took to a spring wagon.[52]

Although Lee was not involved in any direct military engagements during the following months, the army was active in maneuvering to keep Meade’s army in check. Lee remained disabled, as he noted in a reply to General Polk on October 26, 1863, “I have been for more than a month a great sufferer from rheumatism in my back, so that I can hardly get about.”[53]

In December, the army went into winter headquarters and his symptoms seemed to abate; Lee noted in a letter to his wife January 15, 1864, “As regards myself I am pretty well & comfortable enough in my tent. I should be more so I know in a house, but I have none to go to.”[54] No comments of symptoms by Lee related to his illness are noted in his writings until early April 1864.

In a letter to his son Custis written April 9, 1864, Lee states, “I feel a marked change in my strength since my attack last spring at Fredericksburg, and am less competent for my duty than ever.”[55]

From the Wilderness Campaign in May 1864 until Lee’s surrender at Appomattox on April 9, 1865, Lee’s personal letters were fewer and shorter, with little mention of illness other than an intestinal complaint that appeared to be unrelated to his previous “rheumatism” symptoms. His direct military engagement was relatively continuous and, as he had demonstrated in past, he wrote little of his personal issues during these active military engagements.

Intestinal symptoms occurred on the night of May 24, 1864. This illness was not related to his heart disease. “He was loath, as always, to yield to sickness and on the 24th tried to transact army business as usual.”[56] The stress of command and the effects of illness took a toll on Lee’s professional demeanor. “Lee was worse on the 25th and confined to his tent. He must endure the pain and debilitating symptoms. His grip on himself weakened, and he had a violent scene with Colonel Venable, who argued some point with him. When Venable emerged from the tent, Major McClellan remembered, in a state of flurry and excitement, full to bursting, and he blurted out, ‘I have just told the old man that he is not fit to command this army, and that he better send for Beauregard.’”[57]

On June 19, 1864, the Siege of Petersburg begins. Lee continues to live in a tent, “It is from no desire of exposure or hazard that I live in a tent, but from necessity. I must be where I can speedily & at all times attend to the duties of my position & be near or accessible to the officers with whom I have to act.”[58]

During the Siege of Petersburg, lasting from June 1864 until the time Lee and his army evacuated Petersburg to move west, he made visits to Richmond on official business and he occasionally visited with family. He made no mention of illness during this physically rigorous and emotionally trying period. On the morning of evacuation from Petersburg, Longstreet remarked about Lee, “He was ill, suffering from the rheumatic ailment that he had been afflicted with for years, but keener trouble of mind made him in a measure superior to the shooting pains of his disease.”[59]

From the time of evacuation of Petersburg on April 2, until surrender at Appomattox on April 9, Lee was under extreme physical and emotional stress. He made no mention of illness in his writings during this time. However, Walter Taylor, Lee’s Adjutant does comment, “It was only during the last year of the war, when his health was somewhat impaired [that his staff moved his effects into a house and turned in his tent to the quartermaster]”.[60]

Following the war, Lee eventually resided in Lexington, VA, as President of Washington College. Initially, while in Lexington, Lee made some relatively minor comments regarding some physical limitations, but he was able to travel on college business and to testify at Jefferson Davis’ trial in Washington, DC.

However, his health became more of an issue, which his son, Robert E. Lee, Jr. notes in October 1869:

The attack of cold from which my father suffered in October had been very severe. Rapid exercise on horseback or on foot produced pain and difficulty in breathing. After he was considered by most of his friends to have gotten well over it, it was very evident to his doctors and himself that there was a serious trouble about the heart, and he often had great weariness and depression. His letters written during this year to his immediate family show that he was constantly in pain and had begun to look upon himself as an invalid.[61]

These symptoms persisted through the winter, when in March 1870 he makes plans to travel south with his daughter Agnes, “The doctors and others think I had better go to the South in the hope of relieving the effects of the cold, under which I have been laboring all winter.”[62]

During his trip, while in Richmond, Lee consulted physicians: “Yesterday, the doctors, Houston, McCaw and Cunningham, examined me for two hours, and, I believe contemplate returning today. They say they will make up their opinion and communicate it to Dr. Barton, who will write me what to do.”[63] Dr. Barton was Lee’s physician in Lexington.

When in Richmond with his daughter Agnes, he had a chance encounter with Col. John S. Mosby who wrote, “In March, 1870, I was walking across the bridge connecting the Ballard and Exchange hotels, in Richmond, and to my surprise I met General Lee and his daughter. The general was pale and haggard, and did not look like the Apollo I had known in the army.”[64]

In a telling and key letter to a family friend, Gen. R.H. Chilton, April 7, 1870, while in Savannah, Lee writes, “I am suffering from an aggravation of the attack I had in ’63, just before the battle of Chancellorsville & the Drs Think that I shall be partially relieved on walking in warm climate.”[65] The symptoms Lee describes in this letter are diagnostic of coronary artery disease; he relates these symptoms to the onset of his illness in 1863 confirming the diagnosis of symptomatic coronary artery disease at the onset of his symptoms.

He writes again during his trip, in a letter to his wife on April 11, “I feel stronger than when I came. The warm weather has dispelled some of the rheumatic pains in my back, but I perceive no change in the stricture in my chest. If I attempt to walk beyond a very slow gait, the pain is always there.”[66] Lee mentions in a later letter to his wife, dated  April 17:  “I hope I am a little better. I seem to be stronger and to walk with less difficulty…please say to Dr. Barton that I have received his letter and am obliged to him for his kind advice. I shall begin today with his new prescriptions and will follow them strictly.”[67] Dr. Bartonreceived the information from the consultations with the physicians while in Richmond in March; Dr. Barton, in turn, responded to Lee with recommendations. There is no known existing documentation of the prescriptions provided by Dr. Barton.

In an April 18  letter to his wife while he was still in Savannah, GA, Lee comments on an ominous change in his symptoms; it is the first time he mentions rest angina, an indication of progression of his heart disease; angina at rest often predicts an imminent heart attack:

I hope I am better, I know that I am stronger, but I still have the pain in my chest whenever I walk. I have felt it also occasionally of late when quiescent, but not badly, which is new. To-day Doctors Arnold and Reed, of this city, examined me for about an hour. They concur in the opinion of the other physicians, and think it pretty certain that my trouble arises from some adhesion of the parts, not from injury of the lungs and heart, but that the pericardium may not be implicated, and the adhesion may be between the pleura and ——-, I have forgotten the name. The visit was at the urgent entreaty of friends, which I could not well resist, and perhaps their opinion is not fully matured. I am continuing the prescriptions of Drs. Barton and Madison. My rheumatic pains, either from the effects of the medicine or the climate, or both have diminished, but the pain along the breast bone ever returns on my making any exertion.[68]

Lee’s visits to physicians increase in frequency; in this letter, Lee’s physicians do not make a connection between his symptoms and the presence of coronary artery disease.

On May 7, 1870, in a letter to his daughter Mildred, he writes, “I am better, I hope, certainly am stronger and have less pain, but am far from comfortable, and have little ability to move or do anything, though am growing large and fat. Perhaps that is the cause. I will have to spend some days in Richmond at the doctors’ request, as they wish to examine me again and more thoroughly.”[69] There is no record available of that visit to the physicians in Richmond aside from Lee mentioning in a letter to his daughter Mildred on  May 23, “I have seen Dr. Houston this morning, and am to have a great medicine talk to-morrow.”[70] Mrs. Lee describes her husband, “He looks fatter, but I do not like his complexion and he still seems stiff.”[71]

Lee traveled to Baltimore on July 1, 1870 to consult Dr. Thomas H. Buckler about his health. In a letter to his wife, he writes:

Dr. Buckler came in to see me this morning, and examined me, stripped, for two hours. He says he finds my lungs working well, the action of my heart a little too much diffused, but nothing to injure. He is inclined to think that my whole difficulty arises from rheumatic excitement, both the first attack in front of Fredericksburg and the second last winter. Says I appear to have a rheumatic constitution, must guard against cold, and keep out in the air, exercise, etc., as the other physicians prescribe. He will see me again. In the meantime, he has told me to try lemon juice and watch the effect.[72]

In a letter to Dr. Buckler, Lee mentions, “My rheumatic pains continue, but have diminished, and that in my shoulder, I think, has lessened under application of the blister. I shall endeavor to be well by the fall.”[73]

Through much of August 1870, Lee spends time at a variety of hot springs at the recommendation of his physicians Dr. Houston and Dr. Cabell, but finds the hot springs “wearying at these public places and the benefit hardly worth the cost.”[74] In his last letter, written on the day he had the onset of his final illness, he wrote in a September 28 letter to a friend Mr. Tagart, “In answer to your question, I reply that I am much better. I do not know whether it is owing to having seen you and Dr. Buckler last summer, or to my visit to the Hot Springs. Perhaps both. But my pains are less, and my strength greater. In fact, I suppose I am well as I shall be.”[75]

LEE’S LAST ILLNESS

Drs. Howard Thornton Barton and Robert L. Madison[76] give accounts of Lee’s last illness beginning in the evening of September 28, 1870 until his death , on  October 12,. Colonel William Preston Johnston was present at the time of Lee’s final illness and death and provides additional observations. The following provides a summary from these accounts:

On September 28, 1870, upon returning from vestry services, Lee was taken with an inability to speak, accompanied by impaired consciousness and a disposition to dose [doze]. His pulse was slightly accelerated and weak, extremities cool and face flushed. They regarded his case to be one of venous congestion induced by fatigue. Sinapisms [a plaster containing powdered black mustard; applied to the skin as a counterirritant] were ordered, and a hot footbath, with cold compresses to his head. His symptoms indicating sluggish capillary circulation in the brain, a blister was applied behind each ear and to the back of his neck.[77]

Other treatments used during his final illness – botanical concoctions including podophyllin (extract of American Mayapple), acacia, cinnamon and colocynth (a botanical laxative/irritant), and chemical prescriptions given orally including turpentine, magnesium citrate, potassium salts, strychnine, ammonia acetate and quinine, and cupping with bloodletting and hot mustard pediluvium (footbath), among others – are included in detail by Barton and Madison. Lee’s final hours where characterized by rapid, feeble pule, respirations hurried, and deepening unconsciousness. It was said by his physicians, “General Lee died of a broken heart, and its strings were snapped at Appomattox!”[78] One interpretation of the cause of Lee’s final illness was a stroke; however, progressive heart failure ending in cardiogenic shock and death can explain this sequence of events.

Lee was in good health and led a vigorous life until age 56 years. In March 1863, while at Fredericksburg and before Chancellorsville, he first developed symptoms of a major illness characterized by chest, back and arm pain associated with what he described as a “cold.” He was significantly debilitated for several weeks, having difficulty moving about and carrying out his duties in commanding the Army of Northern Virginia. Lee’s physicians attributed his symptoms to “rheumatism and pericarditis;” this was the typical diagnosis for these symptoms given the state of knowledge of cardiac disease in the mid to late nineteenth century.

The onset of symptoms and physical limitations Lee described in letters to his family are consistent with a myocardial infarction. It is commonplace to confuse the symptoms of a heart attack with symptoms of the “flu” or “cold.”[79] Viral myocarditis is less likely a cause of these symptoms in light of his subsequent clinical course.

In the letter Lee wrote to General Chilton in March 1870, Lee clearly describes his symptoms of angina; in modern practice of cardiology, the symptoms he describes are diagnostic of angina. Lee describes these symptoms as a continuation of the onset of his illness beginning in 1863. This is evidence that coronary artery disease was the cause of his illness dating to March 1863. In a male, symptoms characteristic of angina have a high diagnostic probability for coronary artery disease.[80]

Severe aortic valve narrowing is another form of heart disease causing angina pectoris. However, mid-nineteenth century physicians recognized valvular heart disease associated with a cardiac murmur. Lee’s physicians never noted a cardiac murmur; however, cardiac auscultation was not refined and in common use until sometime after Lee’s death. Therefore, it is not likely, but not certain, whether he had significant valvular heart disease as a contributing cause of his symptoms.

The chronology of Lee’s illness is consistent with coronary artery disease, beginning with the relatively abrupt onset of his symptoms most likely related to an acute myocardial infarction. It is common for the presenting manifestation of coronary artery disease to be an acute myocardial infarction. There is nothing reported by Lee of any symptoms of new onset angina or unstable angina before the onset of his acute illness in March 1863.

Lee’s symptoms tended to wax and wane; this clinical course is typical of the natural history of coronary artery disease. Following Chancellorsville in May 1863, Lee prepared to move north. During that period of time and around the time of Gettysburg, Lee does mention some symptoms, but official correspondence dominates his writings.

Following Gettysburg, shortly after withdrawal of the Army of Northern Virginia from Pennsylvania, in a letter to Jefferson Davis, Lee writes a detailed description of his symptoms and the disability he has been suffering. Lee requests to be relieved of duty because of his debilitating symptoms.

Having lost Jackson the previous spring at Chancellorsville, Lee likely needed to be more available in the field for direct observation; this would have been more physically demanding and Lee may have had less than the ideal amount of information from the field. Lee commented on Jackson at Chancellorsville, “Such an executive officer the sun never shone on. I have but to show him my design, and I know that if it can be done, it will be done. No need for me to send or watch him. Straight as the needle to the pole he advanced to the execution of my purpose.”[81] Presumably, Lee could not depend on Jackson’s replacement to perform his duties in a similar fashion.

During the subsequent years of the Civil War, Lee does comment that his symptoms wax and wane. During the Wilderness Campaign and the Siege of Petersburg, 1864-65, Lee makes few comments about his health. Clearly, the physical demands put on Lee during the period when the Army of Northern Virginia evacuated Petersburg and moved west to Appomattox were likely great, yet Lee does not mention symptoms. This silence related to his illness is typical letter writing for Lee during active military engagement.

During the years following the Civil War, Lee has progressive symptoms of angina; these symptoms became increasingly debilitating. Lee’s physical appearance declines as seen in his portraits over a relatively brief period. On multiple occasions, he comments on his symptoms becoming progressively worse, leading to rest angina described in a letter to his wife in April 1870. His wife and others comment on his progressive appearance of debility. Physicians prominent in Richmond, Savannah, and Baltimore performed consultations on multiple occasions. None of these records are extant, although Lee does comment occasionally on the physicians’ findings and recommendations. Despite progressive symptoms, Lee remains as president of Washington College in Lexington, VA.

As to his final illness, the course of events is conjecture. This conjecture remains despite a detailed published description of his final illness by his physicians, Drs. Madison and Barton. Lee developed symptoms of shortness of breath likely related to congestive heart failure. An account of physical examination of his lungs is not available; auscultation of the lungs was just coming into use. Lee’s physicians described him as having a rapid feeble pulse noted in his last days. Atrial fibrillation might have been the cause of abnormal pulse. His had an accelerated respiratory rate and cool extremities, consistent with a failing heart.

There has been conjecture that his initial presenting symptoms of difficulty speaking may have been aphasia resulting from a stroke. However, as evidence against a stroke, those present did not describe focal weakness or sensory abnormality. Although his difficulty speaking could have been the result of a stroke without other neurologic manifestations. A stroke could have been embolic, particularly if he had atrial fibrillation, a known source of blood clots that could have gone to his brain causing a stroke. In his final days, his condition progressively declined, likely related to gradually worsening heart failure.

Lee’s treatment during the several years of progression of his illness and during his final days was commensurate with the state of medical knowledge during the mid to late nineteenth century. His treatment consisted of combination of allopathic/regular, botanical, and homeopathic medical measures available at that time.

Lee’s Lexington physicians had training from excellent institutions.[82] Howard Thornton Barton, MD, graduated second in his class from Virginia Military Institute in 1843 and received his medical degree from the University of Pennsylvania, a well-respected medical school. He moved to Lexington, VA, following the war to practice medicine and serve as post physician atVMI .

Robert L. Madison, MD, graduated from William and Mary College in 1849. He received his medical degree from Jefferson Medical College in Philadelphia in 1851. He served on the faculty of Virginia Military Institute and was personal physician for Major Thomas J. Jackson before the onset of the Civil War. He served as a medical officer in the Confederate States Army.

Based on the state of medical knowledge at the time of Lee’s death, his treatment was good quality. Sectarian medicine was still common at that time and probably, because of this influence, Lee received a combination of allopathic, botanical and homeopathic medical treatment.

Physicians did not recognize risk factors for coronary artery disease until the advent of the Framingham study in 1947.[83] Lee’s risk factors for coronary artery disease, as determined by historical records, appeared to be few. There was no known family history of coronary artery disease, Lee did not use tobacco, his activity level was not sedentary, his diet was moderate, and he was not overweight until the last year of his life. Physicians did not measure Lee’s blood pressure; hence, it is unknown whether he had high blood pressure as a coronary artery disease risk factor.

Medications directed at the pathophysiology of heart disease were relatively unknown during Lee’s life. In 1867, Brunton first described amyl nitrite as a treatment for patients with angina pectoris. He ascribed its action, using sphygmographic tracings, to the relaxation of the vessels and reduction of the arterial tension. Widespread clinical use of amyl nitrite for angina did not come for some years after Lee’s death.

Similarly, nitroglycerine, a current mainstay of treatment for angina pectoris, having been first synthesized in 1846 in the search for a better explosive, did not come in to medical use until the late nineteenth century. Aspirin, well known in modern cardiology practice and used primarily as an antiplatelet drug to prevent or reduce coronary thrombosis, was unknown during Lee’s lifetime.

Lee died at the age of 63 years. The average age or life expectancy for a male born in 1810 was approximately 42 years. However, mortality rates were very high in infancy, drop rapidly in childhood, reach their low in late childhood and adolescence, and then begin to increase with age. For a man age 60 in the late nineteenth century, on average an additional 10 years of life was common.[84]

In conclusion, angina pectoris significantly incapacitated Lee; he had symptoms of congestive heart failure later in life. The onset of his illness in March 1863 was likely an acute myocardial infarction. The symptoms he had as early as the spring of 1863, in his own words, prevented him from conducting his “hands on” duties as commanding General of the Army of Northern Virginia.

Lee’s debilitation became more of an issue following his loss of General Jackson at Chancellorsville in spring 1863, most particularly noted with Jackson’s absence at Gettysburg. Lee, in fact, submitted his resignation to President Davis following his withdrawal from Gettysburg because he did not feel physically fit to perform his duties.

Despite his illness with the accompanying disability, Lee performed his duties as commander of the Army of Northern Virginia. Disability from his heart disease must have added additional difficulty to his duties; his ability to carry out his duties under these circumstances speaks to his determination. His request to step down as commander of the Army of Northern Virginia, based on his letter to Davis, was prompted by his desire to do what he thought was best for his army, rather than for himself.

Based on the status of medical education, medical knowledge of coronary artery disease and the training and background of Lee’s physicians, Lee received state of the art treatment. Nonetheless, the treatments provided for Lee would not have improved his symptoms nor would they have prolonged his life.

One can wonder what course history might have taken if knowledge of the pathophysiology of coronary artery disease, which was just becoming recognized during Lee’s lifetime, was more widely applied to Lee’s benefit. Additionally, what course would history have taken if drugs that we now know to be efficacious in the treatment of coronary artery disease and present in Lee’s lifetime – nitroglycerine, amyl nitrite and salicylic acid – were clinically available to treat Lee?

Sources

  1. Howard Barton and Robert Madison, “A Letter from Lexington,” Richmond and Louisville Journal 9 (1870) 516-23.
  2. Marven P. Rozear, E. Wayne Massey, et al. “R.E. Lee’s Stroke,” Virginia Magazine of History and Biography 98 (1990) 291-308.
  3. T.H. Laennec, a Treatise on the Diseases of the Chest, and on Mediate Auscultation, (Philadelphia: Thomas Cowperthwaite and Co., 1838). The use of the stethoscope dates to the nineteenth century with the modern binaural stethoscope coming into use about the time of Lee’s final illness and death. There are some vague descriptions by Lee in letters related to his physicians examining his chest, but no details regarding cardiac examination.
  4. For a description of one of the earlier devices for blood pressure measurement with a sphygmomanometer see, Leonard Hill and Harold Barnard, “A Simple and Accurate Form of Sphygmometer or Arterial Pressure Gauge Contrived for Clinical Use”, BMJ 2 (1897) 904; and for an historical review see Jeremy Booth, “A Short History of Blood Pressure Measurement”, P. Roy. Soc Med 70 (1977):793-99.
  5. H. Garrod, “On the Relative Duration of the Component Parts of the Radial Sphygmograph Trace in Health,” P R Soc London 18 (1870) 351-54.
  6. Gershon-Cohen, “A Short History of Medical Thermometry,” Ann N Y Acad Sci 121 (1964) 4-11; C.A. Wunderlich, “The Course of the Temperature in Disease: A Guide to Clinical Thermometry,” Am J Med Sci 114 (1869) 425-54.
  7. Lester S. King, “III. Medical Sects and Their Influence,” J Amer Med Assoc 248 (1982) 1221-24.; Norman Gevitz, “Sectarian Medicine,” J Amer Med Assoc 257 (1987) 1636-40.; for a comprehensive review of the development of the medical profession including sectarianism and reform see, Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York:  Basic Books, Inc., 1982) 79-144.
  8. For an extensive review of the Confederate Medical Service including the causes, prevalence and treatment of disease in the military during the Civil War. Surgery and infections are reviewed in detail here. H.H. Cunningham, Doctors in Gray: The Confederate Medical Service, (Baton Rouge: Louisiana State University Press, 1960); Michael A. Flannery, Civil War Pharmacy:  A History of Drugs, Drug Supply and Provision, and Therapeutics for the Union and Confederacy, (New York, London, and Oxford: Pharmaceutical Products Press, The Haworth Press, Inc., 2004).
  9. Codell Carter, “Ignaz Semmelweis, Carl Mayrhoffer and the Rise of Germ Theory,” Med Hist 29 (1985) 33-53; Joseph Lister, “On the Effects of the Antiseptic System of Treatment Upon the Salubrity of a Surgical Hospital,” 1 Lancet (1870) 4-6; Joseph Lister, “On the Antiseptic Principle in the Practice of Surgery,” 2 BMJ (1867) 246-48.
  10. David B. Pryor, Frank E. Harrell, Jr., et al, “Estimating the Likelihood of Significant Coronary Artery Disease, Am J Med 75 (1983) 771-80. In this paper it was reported that when a male age 60-69 years of age has a typical history of angina pectoris, the average predictive probability of having significant coronary artery disease is greater than 90%; D. Mozaffarian, C.L. Bryson, et al, “Anginal Symptoms Consistently Predict Total Mortality Among Outpatients with Coronary Artery Disease,” Am Heart J 146 (2003) 1015-22. In this paper, outpatients with coronary artery disease with self-reported angina symptoms consistently predict mortality.
  11. Austin Flint, A Compendium of Percussion and Auscultation and of the Physical Diagnosis of Diseases Affecting the Lungs and Heart, (New York: William Wood & Company, 1880).
  12. Lester S. King and Marjorie C. Meehan, “A History of the Autopsy”, Am J Pathol 73 (1973) 514-44. This paper reviews the history of the use of autopsy and gives a good description of its use in the 19th
  13. Bruce Fye, “A history of the Origin, Evolution, and Impact of Electrocardiography,” Am J Cardiol 73 (1994) 937-49; George F. Barker, Ed., Roentgen Rays: Memoirs by Roentgen, Stokes and J.J. Thomson, (New York and London: Harper and Brothers Publishers, 1899.
  14. Booth, “A Short History of Blood Pressure Measurement”, (n.3), 793-99.
  15. M.S. Pearce, “A Brief History of the Clinical Thermometer”, Q J Med 95 (2002) 251-2.
  16. William Heberden, Medical Transactions, Published by the College of Physicians in London. Volume the Second (London: S. Baker, and J. Dodsley, 1772) 59-63.
  17. Caleb Hillier Parry, An Inquiry into the Symptoms and Causes of the Syncope Anginosa, Commonly Called Angina Pectoris (Bath: Crutwell and Sold by Cadell and Davies, Strand, London, 1799) 2-3.
  18. James B. Herrick, “Clinical Features of Sudden Obstruction of the Coronary Arteries,” J Amer Med Assoc 59 (1912) 2015-22.
  19. Austin Flint, Diseases of the Heart, (Philadelphia: Blanchard and Lea, 1859, 254-66.
  20. Gordon Dammann, Pictorial Encyclopedia of Civil War Medical Instruments and Equipment (Missoula: Pictorial Histories Publishing Company, 1997). For a review of medical and surgical instruments available during the Civil War.
  21. Cunningham, Doctors in Gray, (n. 8) 231. Dr. Cunningham notes, “It was part of the tragedy of the Civil War that these surgeons knew nothing of the doctrine of sepsis and the proper use of antiseptics.”; see also an early description by Lister on antisepsis use in surgery, Joseph Lister, “An Address on the Antiseptic System of Treatment in Surgery,” vol. ii BMJ (1868) 53-56.
  22. Codell Carter, “Ignaz Semmelweis, Carl Mayrhoffer and the Rise of Germ Theory,” Med Hist 29 (1985) 33-53.; for a flavor of the controversy involved with the theory put forth by Semmelweis see: Letter to the editor by Dr. Hecker in Medical Times and Gazette February 8, 1862, p 142 and response by Semmelweis June 7, 1862, p 601; For detailed account of Semmelweis’ work see: Ignaz Semmelweis, The Etiology, Concept, and Prophylaxis of Childbed Fever, ed. and trans. K. Codell Carter (Madison: The University of Wisconsin Press, 1983).
  23. Henry J. Bigelow, “Insensibility During Surgical Operations Produced by Inhalation,” The Boston Medical and Surgical Journal 35 (1846) 18 November 1846.
  24. Austin Flint, A Manual of Percussion and Auscultation; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism (London: J&A Churchill, 1876) and in a series: Austin Flint, “Original Lectures. Philadelphia County Medical Society Lectures. On the Physical Exploration of the Lungs by Means of Auscultation and Percussion.” The Medical News. A weekly Journal of Medical Science 42 (1883) Lecture I p 3-8; Lecture II p 29-36; Lecture III p 61-67.
  25. Wunderlich, “The Course of the Temperature in Disease” (n.5) 425-54.
  26. Keith Wilbur, Civil War Medicine, (Guilford Connecticut: The Globe Pequot Press, 1998). 65. Dr. Wilbur notes, “The clinical thermometer was fragile, cumbersome, and the patient’s temperature was taken from the axilla.”
  27. Editorial (Author Anonymous), “The Prevention of Apoplexy,” BMJ 1 (1905) 782-3. More than a hundred years ago there is noted a criticism of technology creating a distance between the physician and the patient, much as we hear today about more advanced technology; interestingly, the sphygmomanometer is currently in daily use by medical and lay people for blood pressure measurement.
  28. Flint, Diseases of the Heart, (n. 1) 254-66.
  29. Henry Hartshorne, A Conspectus of the Medical Sciences Comprising Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics for the Use of Students (Philadelphia: Henry C. Lea, 1869) 694.
  30. Flint, Diseases of the Heart, (n. 1) 265-66.
  31. Lauder Brunton, “Use of Amyl Nitrite in Angina Pectoris,” Lancet 90 (1867) 97-8.
  32. Lauder Brunton, “Nitrite of Amyl in Angina Pectoris,” (1870) In Collected Papers on Circulation and Respiration (London: Macmillan and Co., Limited, 1907) 185-96.
  33. Constantine Herring, “Glonoine, a New Medicine for Headache, &c.,” American Journal of Homeopathy 4 (1849) 1-3. Herring’s name for nitroglycerine was Glonoine.
  34. William Murrell, “Nitro-glycerine as a Remedy for Angina Pectoris,” 113 (1879) 113-5.
  35. David B. Jack, “One Hundred Years of Aspirin,” Lancet 350 (1997) 437-439.
  36. Douglas Southall Freeman, E. Lee: A Biography (New York, London: Charles Scribner’s Sons, 1934) Vol I, 12.
  37. Ibid, vol IV, 524-25; Edward J. Van Liere, “The Health of General Robert E. Lee,” WV Med J 72 (1976) 113-16; Richard D. Manwaring and Curtis G. Trible, “The Cardiac Illness of General Robert E. Lee,” J Surg Gynecol Obstet 174 (1992) 237-44; Marvin P. Rozear, E. Wayne Massey, et al. “R. E. Lee’s Stroke,” Virginia Magazine of History and Biography 98 (1990) 291-308.
  38. Freeman, E. Lee (n.48) 4 vols.
  39. Winfield Scott to Pillow Court of Inquiry, 1st session, 30th Congress in Freeman, E. Lee, (n.48) 272. A pedegral is a lava field more than five miles wide, broken into great blocks and fissures.
  40. Freeman, E. Lee, (no.48) 306.
  41. Lee to John MacKay, September 8, 1845, Robert E. Lee Collection, Manuscript, Archives and Rare Book Library, Emory University.
  42. Freeman, E. Lee (n. 51), vol I, 452; J. William Jones, Personal Reminiscences, Anecdotes, and Letters of General Robert E. Lee (New York: D. Appleton and Company, 1875) 169. This book gives a more detailed overview of Lee’s habits in Chapter V “His Spirit of Self-denial for the good of others.” 167-85.
  43. Clifford Dowdy, Ed., The Wartime Papers of R. E. Lee (New York: Bramhall House, 1961) 419. In this communication to his wife, Lee comments on what is probably the initial onset of his cardiac illness. It is common for an acute myocardial infarction to be confused symptomatically with a “cold” or “flu” by patients, hence going unrecognized, even in modern times, by patients and physicians. In the modern era, physicians recognize this interpretation of symptoms that can result in delay of treatment of myocardial infarction. See, R. Horne, D. James, et al., “Patients’ Interpretation of Symptoms as a Cause of Delay in Reaching Hospital During Acute Myocardial Infarction,” Heart 83 (2000) 388-93.
  44. Lee to Margaret Stuart, 5 April 1863, Near Fredericksburg in Freeman, “Lee and the Ladies: Unpublished Letters of Robert E. Lee”, Scribers Magazine 87 (1925) 462-64.
  1. Samuel Merrifield Bemiss, Days Before Yesterday, A Letter, (Privately Printed, 1961) 35. In a letter to his children, Dr. Bemiss, writes, “For over a week past he (Lee) has been sick, and I was first called to see him in consultation, then his physician has taken sick and he is now my patient, and I visit him every afternoon.” Dr. Bemiss was a medical officer assigned to General Lee’s staff. The Bemiss papers are in the private possession of the Bemiss family of Richmond Virginia. This book contains a few of Bemiss’ letters.
  2. Lee to James Seddon, 9 April 1863 in Dowdy, Wartime Papers, (n.55) 431.
  3. Lee to his daughter Agnes Lee, 11 April 1863 in Dowdy, Wartime Papers (n.55), 431.
  4. Lee to his wife Mary, 12 April 1863 in Dowdy, Wartime Papers (n.55) 432.
  5. Lee to his wife, 19 April 1863 in Dowdy, Wartime Papers (n.55) 437-8. During this period, it is clear from Lee’s letters that his illness persists. He appears to be at times optimistic about his symptoms, but his complaints come through consistently.
  6. Lee to Jefferson Davis, 8 August 1863 in Dowdy, Wartime Papers (n.55) 589-91.
  7. Lee to Jefferson Davis, 22 August 1863 in Dowdy, Wartime Papers (n.55) 593.
  8. Lee to his wife, 4 September 1863 in Dowdy, Wartime Papers (n.55) 595.
  9. Lee to General Leonidas Polk, 26 October 1863 in Dowdy Wartime Papers (n.55) 614.
  10. Lee to his wife, 15 January 1864 in Dowdy, Wartime Papers (n.55) 652. This is at a time when Lee was less active in winter at headquarters in Virginia.
  11. Lee to his son Custis, 9 April 1864 in Dowdy, Wartime Papers (n.55) 695.
  12. Freeman, E. Lee (n.48) Vol. III 356.
  13. Ibid, 359.
  14. Dowdy, Wartime Papers (n.55) 855. This is another example how Lee denied himself usual comforts. This likely had a negative effect on his health.
  15. James Longstreet, From Manassas to Appomattox, Memoirs of the Civil War in America (Philadelphia: J. B. Lippincott, 1908) 604.
  16. Walter H. Taylor, Four Years with General Lee (New York: D. Appleton and Company, 1878) 150.
  17. Robert E. Lee, Jr., Recollections and Letters of General Robert E. Lee (Garden City: Garden City Publishing Company, 1926) 379-80. General Lee’s son wrote from a collection of letters written to and from Lee, but also was intimately associated with his father and adds many important recollections of his life and particularly his illness.
  18. Lee to his daughter Mildred, 21 March 1870 in Lee, Recollections and Letters, (n.73) 384.
  19. Lee to his wife, 29 March 1870, in Lee, Recollections and Letters, (n.73) 388-89. There is record of the physicians mentioned in this letter. They were prominent physicians in the state of Virginia active in state medical organizations. Dr. Barton was Lee’s private physician in Lexington. There is letter from Dr. Houston to Dr. Bemiss requesting medical information about Lee when Lee was treated by Bemiss in 1863; this letter is found in Bemiss, Days Before Yesterday (n.57) 41. However, I cannot find any records containing details of Lee’s visit to the mentioned physicians.
  20. Charles Wells Russell, Ed., The Memoirs of Colonel John S. Mosby (Boston: Little, Brown, and Company, 1917) 380.
  21. Lee to General R. H. Chilton, 7 April 1870 in Eleanor S. Brockenbrough Library, The Museum of the Confederacy, Richmond, Virginia. This letter was written at a time when it is clear that Lee was suffering with classic symptoms of angina pectoris. The key point of this letter is he ties these symptoms to the onset of his cardiac illness in early spring of 1863.
  22. Lee to his Wife, 11 April 1870, Savannah, in Lee, Jr., Recollections and Letters (n.73) 397.
  23. Lee to his wife, 17 April 1870, Savannah, in Lee, Jr., Recollections and Letters, (n.73)
  24. Lee to his wife, 18 April 1870, Savannah, in Lee, Jr., Recollections and Letters, (n.73) 397-99. It is clear from this description by Lee that his symptoms have significantly progressed to the point where he is now having symptoms of angina at rest. This is a sign of unstable angina that typically portends an increased cardiac event and/or death within weeks to months.
  25. Lee to his daughter Mildred, 7 May 1870, Brandon, Lee Jr., Recollections and Letters 403-4.
  26. Lee to his daughter Mildred, 23 May 1870, Richmond, in Lee, Jr., Recollections and Letters, (n.73) 411.
  27. Lee to her daughter Mildred, 13 May 1870, in Lee, Jr., Recollections and Letters, (n.73) 405.
  1. Lee to his wife, Baltimore, 2 July 1870, in Lee, Jr., Recollections and Letters (n.73) 413. It is clear that Lee continues to worsen as evidenced by the increased visits to a variety of prominent physicians in Virginia. There are no existing records of the results of these visits except for Lee’s descriptions. The findings of these visits all seem to be about the same with descriptions consistent with the then current knowledge of the diagnosis and treatment of chest pain.
  2. Lee to Dr. Buckler, Lexington, 5 August 1870 in Lee, Jr., Recollections and Letters (n.73) 420. The application of a blister is consistent with the state of knowledge of heart disease in 1870.
  3. Lee to his wife, Hot Springs, 23 August 1870, in Lee, Jr. Recollections and Letters (n.73) 427-29.
  4. Lee to Tagart, Lexington, 28 September 1870, in Lee, Jr., Recollections and Letters, (n.73) 433.
  5. Howard Barton and Robert Madison, “A Letter from Lexington,” Richmond and Louisville Medical Journal 9 (1870) 516-23. This paper published shortly after Lee’s death contains detailed descriptions of his physical state as seen through the eyes of Lee’s nineteenth century physicians, along with details of treatments and doses of oral concoctions. The editorial following the account by Madison and Barton is interesting reading; the author of this editorial puts Barton and Madison in less than a positive light. Comments extracted from this editorial include, “As a rule, those who were prominent on these occasions had only the desire to advertise themselves, and were in no respect fit persons for the positions they sought so eagerly to occupy…There would be an advertising doctor whose charlatan instinct is never satisfied, unless by the perpetual appearance of his name in the secular papers…There were, of course, many distinguished exceptions to this rule; but in the main, it was the old story—the vultures clustering where the lion had fallen.” 670-1.
  6. William Preston Johnston, “His Death and Funeral Obsequies”, J. William Jones, Personal Reminiscences, Anecdotes, and Letters of General Robert E. Lee (n.54) 446-60.
  7. Barton, “A Letter from Lexington” (n.88) 522.
  8. Horne, “Patients’ Interpretation of Symptoms as a Cause of Delay in Reaching Hospital During Acute Myocardial Infarction,” (n.55). Even today, it is common for a patient and at times a physician to misinterpret symptoms as a “cold” or the “flu” in patients with acute myocardial infarction.
  9. Pryor, “Estimating the Likelihood of Significant Coronary Artery Disease,” (n. 10).
  10. F.R Henderson, Stonewall Jackson and the American Civil War, (London: Longmans, Green, and Co., 1919) 477.
  11. Richard D. Mainwaring and Harris D. Riley, ‘The Lexington Physicians of General Robert E. Lee,” South Med J 98 (2005) 800-4. This paper provides some insight into the background, training and experience of Lee’s most frequently consulted physicians.
  12. Syed S. Mahmood, Daniel Levy, et al., “The Framingham Heart Study and the Epidemiology of Cardiovascular Disease: A Historical Perspective,” Lancet 383 (2014) 999-1008.
  13. David Hacker, “Decennial Life Tables for the White Population of the United States, 1790-1900,” Hist Methods 43 (2010) 45-79. The mortality and life expectancy data for the 19th century is not consistent and difficult to make comparisons to modern era. The author of this paper constructs new life tables and feels that this represents more accurately sex- and age-specific mortality.

About the Author

Richard A. Reinhart has had an interest in nineteenth century medical practice and education for several decades. He developed a specific interest in the medical history of Robert E. Lee because it provided an opportunity to study the medical history of a person with heart disease; Lee was prolific and descriptive in his correspondence with family, friends and colleagues providing an opportunity to delve into his medical history; Dr. Reinhart has been a cardiologist for several decades, trained at Ohio State University College of Medicine with postgraduate training at Duke University Medical Center, and notes that, even today, the diagnosis of heart disease in an individual starts with a detailed medical history. When placed in the context of what was known about heart disease in the nineteenth century and with detailed investigation of Lee’s writings, we can make an accurate diagnosis of Lee’s illness and clinical course; one can surmise the effect of this illness on the course of events. Dr. Reinhart recently retired as Professor of Medicine (Emeritus), East Carolina University and lives with his wife in northern Wisconsin.

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