Historical Implications of a Failing Heart Part 2

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. 2

I present Lee’s medical history with the 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, as presented in the previous issue.

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.

Lee, age 56 in 1863. Courtesy of the Library of Congress

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 24^th 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 25^th 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]

Robert E. Lee (sitting), with son G.W.C. (Custis) Lee on left and Walter Taylor on right, April 1865, Richmond. VA.
Courtesy of the Library of Congress

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 D^rs 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. Barton received 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.

Mrs. Robert E. Lee.
Courtesy of the Library of Congress

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 pulse, 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.

Robert E. Lee’s headquarters, Gettysburg, PA.
Courtesy of the Library of Congress

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]

Currier & Ives drawing of the death of Robert E. Lee, October 12, 1870.
Courtesy of the Library of Congress

In conclusion, angina pectoris significantly incapacitated Lee[85]; 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

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; Harris D. Riley, “General Robert E. Lee: His Medical Profile,” Virginia Medical (July 1978) 495-499; John C. Krantz, “The Implications of the Medical History of General Lee,” Virginia Medical Monthly 89 (1959) 306-310.
38. Freeman, E. Lee (n.36) 4 vols.
39. Winfield Scott to Pillow Court of Inquiry, 1^st session, 30^th Congress in Freeman, E. Lee, (n.36) 272. A pedegral is a lava field more than five miles wide, broken into great blocks and fissures.
40. Freeman, E. Lee, (n.36) 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. 36), 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.

45. 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.
46. Lee to James Seddon, 9 April 1863 in Dowdy, Wartime Papers, (n.43) 431.
47. Lee to his daughter Agnes Lee, 11 April 1863 in Dowdy, Wartime Papers (n.43), 431.
48. Lee to his wife Mary, 12 April 1863 in Dowdy, Wartime Papers (n.43) 432.
49. Lee to his wife, 19 April 1863 in Dowdy, Wartime Papers (n.43) 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.
50. Lee to Jefferson Davis, 8 August 1863 in Dowdy, Wartime Papers (n.43) 589-91.
51. Lee to Jefferson Davis, 22 August 1863 in Dowdy, Wartime Papers (n.43) 593.
52. Lee to his wife, 4 September 1863 in Dowdy, Wartime Papers (n.43) 595.
53. Lee to General Leonidas Polk, 26 October 1863 in Dowdy Wartime Papers (n.43) 614.
54. Lee to his wife, 15 January 1864 in Dowdy, Wartime Papers (n.43) 652. This is at a time when Lee was less active in winter at headquarters in Virginia.
55. Lee to his son Custis, 9 April 1864 in Dowdy, Wartime Papers (n.43) 695.
56. Freeman, E. Lee (n.36) Vol. III 356.
57. Ibid, 359.
58. Dowdy, Wartime Papers (n.43) 855. This is another example how Lee denied himself usual comforts. This likely had a negative effect on his health.
59. James Longstreet, From Manassas to Appomattox, Memoirs of the Civil War in America (Philadelphia: J. B. Lippincott, 1908) 604.
60. Walter H. Taylor, Four Years with General Lee (New York: D. Appleton and Company, 1878) 150.
61. 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.
62. Lee to his daughter Mildred, 21 March 1870 in Lee, Recollections and Letters, (n.61) 384.
63. Lee to his wife, 29 March 1870, in Lee, Recollections and Letters, (n.61) 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.45) 41. However, I cannot find any records containing details of Lee’s visit to the mentioned physicians.
64. Charles Wells Russell, Ed., The Memoirs of Colonel John S. Mosby (Boston: Little, Brown, and Company, 1917) 380.
65. 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.
66. Lee to his Wife, 11 April 1870, Savannah, in Lee, Jr., Recollections and Letters (n.61) 397.
67. Lee to his wife, 17 April 1870, Savannah, in Lee, Jr., Recollections and Letters, (n.61)
68. Lee to his wife, 18 April 1870, Savannah, in Lee, Jr., Recollections and Letters, (n.61) 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.
69. Lee to his daughter Mildred, 7 May 1870, Brandon, Lee Jr., Recollections and Letters 403-4.
70. Lee to his daughter Mildred, 23 May 1870, Richmond, in Lee, Jr., Recollections and Letters, (n.61) 411.
71. Lee to her daughter Mildred, 13 May 1870, in Lee, Jr., Recollections and Letters, (n.61) 405.

72. Lee to his wife, Baltimore, 2 July 1870, in Lee, Jr., Recollections and Letters (n.61) 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.
73. Lee to Dr. Buckler, Lexington, 5 August 1870 in Lee, Jr., Recollections and Letters (n.61) 420. The application of a blister is consistent with the state of knowledge of heart disease in 1870.
74. Lee to his wife, Hot Springs, 23 August 1870, in Lee, Jr. Recollections and Letters (n.61) 427-29.
75. Lee to Tagart, Lexington, 28 September 1870, in Lee, Jr., Recollections and Letters, (n.61) 433.
76. 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.
77. William Preston Johnston, “His Death and Funeral Obsequies,” J. William Jones, Personal Reminiscences, Anecdotes, and Letters of General Robert E. Lee, (New York: D. Appleton and Company, 1875) 446-52.
78. Barton, “A Letter from Lexington” (n.76) 522.
79. Horne, “Patients’ Interpretation of Symptoms as a Cause of Delay in Reaching Hospital During Acute Myocardial Infarction,” (n.43). 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.
80. David B. Pryor, Frank E. Harrell, Jr., et al, “Estimating the Likelihood of Significant Coronary Artery Disease,” Am J Med 75 (1983) 771-80.
81. F.R Henderson, Stonewall Jackson and the American Civil War, (London: Longmans, Green, and Co., 1919) 477.
82. 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.
83. 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.
84. 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 19^th 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.
85. This is supported by the reports of Krantz (n.37) 2-3, “In the spring of 1863 Lee was eager to take the offensive again and carry the war into Maryland and Pennsylvania. At a crucial point in the planning of his campaign against Union forces under Hooker, the fates conspired against the Confederacy and Lee became ill.”; Van Liere (n.37) 113-114, “In the spring of 1863, General Lee was planning on carrying the war into Maryland and Pennsylvania, but, unfortunately, he became ill at a crucial point in planning the campaign…” and Mainwaring and Tribble (n.37) 243, “…his illness had a major influence on the battle of Gettysburg.”
    

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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.