1863, end of March. — For the first time during the war, General Lee required medical attention. He was then aged fifty-six, florid, •about 5 feet 10½ inches in height, and weighed about 165 pounds. His physical p522 experience had been that of the average soldier. Periods of active campaigning had alternated with close occupation at a desk. As the commanding general of the army defending his country's capital, he carried heavy responsibilities. He was physically strong and athletic, capable of sustaining long hours without any evidence of fatigue. His teeth were good. There is no record of any serious illness before the war. His habits in all things were exemplary. He rode horseback regularly for exercise. His father had died of unknown cause, at the age of sixty-two. Ann Carter Lee, his mother, who lived to be only fifty-six, was long a semi-invalid, suffering probably from arthritis or perhaps from heart disease. General Lee's wife sustained a pelvic infection in childbirth and thereafter developed a general arthritis.
Upon examination, the diagnosis made was that of "inflammation of the heart-sac," following a throat infection. Lee was sufficiently sick to require treatment away from the army. He suffered a good deal of pain in chest, back, and arms. "It came on in paroxysms, was quite sharp," he wrote. Doctors examined "my lungs, my heart, circulation, etc. and I believe they pronounced me tolerable sound."
1863, April 10. — Lee was reported better and was expected soon to be well.1
1863, about April 15. — The patient resumed his military duties but was confined to his tent for a day or two at the end of the month.
1863, October. — An attack described variously as "sciatica," "rheumatism," and "lumbago," involving arm and back and making it impossible for Lee to ride for about a week.
1864, May-June. — A ten-day debilitating diarrhoea.
1865‑67. — No recurrence of any acute symptoms, but occasional reference is made to trouble with "rheumatism" of the arms, shoulder, and back, with "sciatica" and with "lumbago." Lee showed an increased susceptibility to bad colds. After 1865 his photographs show him aging rapidly.
1866‑68. — The General began to talk of getting old, and of having only a short span of life left him.
1869, October. — Lee had another illness which he mentioned in his letters as a "heavy cold," but from the importance attached to it by physicians in later discussion of the General's case, it is believed to have been very similar to the attack prior to the battle of Chancellorsville. He was not long in bed and began to go about in some two weeks.
1869, winter. — Following his illness, the General discovered that p523 rapid exercise produced pain and difficulty in breathing. He suffered from weariness and depression, and was almost constantly in pain while walking. It was reported among his friends that he had some serious trouble "about his heart." He began to look upon himself as virtually an invalid, and his appearance became somewhat haggard. In the opinion of his friends he "aged" greatly during this winter.
1870, February. — He hoped he was better and he felt stronger, but he could not walk with comfort much farther than •200 yards. When he got on his horse, however, he could ride with fair comfort.
1870, March. — His physicians were very anxious that he should visit a Southern climate as soon as possible.
1870, March-May. — He made an exhausting six weeks' tour through the Carolinas and Georgia and into Florida. Everywhere he went there were crowds, excitement, cheering, receptions, and dinners. At first he noticed that the warmer weather dispelled some of the rheumatic pains in his back, but he said: "I perceive no change in the stricture in my chest. If I attempt to go beyond a very slow gait, the pain is always there. It is all true what the doctors say about its being aggravated by any fresh cold, but how to avoid taking cold is the question. It seems to me to be impossible. . . . My complaint . . . is fixed and old." As the strain of the tour continued, he had the pain whenever he moved about, and he felt it occasionally even when he was quiet, though it was not so severe then as when he was walking. His rheumatic pains were less but his "pain along the breastbone always returns on making any exertion." During the tour he gained in weight and became more florid.
1870, April. — While in Savannah, Ga., he was examined by two physicians. He wrote: "They . . . think it pretty certain that my trouble arises from some adhesion of the parts, than from any 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."
1870, end of May. — On his return from this tour, and after two weeks of rest, the General was examined in Richmond. A brief letter from this physician, addressed to the army surgeon who treated the General in 1863, is the only direct medical testimony available. This physicians said that the General's symptoms were obscure but indicated chronic pericarditis. He wished to know whether the General's trouble in 1863 had been an acute attack of that disease.
1870, July. — After a further period of rest, the General was able to travel alone and to ride horseback. He was somewhat stronger and p524 attended to his regular duties. Examined in Baltimore in July by Doctor T. H. Buckler, then of Paris, he reported to his wife: "He [Doctor Buckler] says he finds my lungs working well, the action of the 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 taking cold, 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 effects."
1870, July 15. — He caught a fresh cold and was suffering very much from hot weather, to which he now seemed to have an added susceptibility.
1870, Aug. 5. — Having returned home, he felt better. The "rheumatic" pains continued but had diminished. The pain in his shoulders was lessened, he thought, "under the application of the blister." He told his physician, "I shall endeavor to be well by the fall."
1870, August. — He went to the springs, where he took the "broiler" and the "hot spout." For a while he noticed no change except a shift in the seat of his pains, but after ten days he felt somewhat better.
1870, Sept. 28, forenoon. — He wrote a friend, "I am much better. . . . My pains are less and strength greater."
1870, Sept. 28, afternoon. — His terminal illness began.2
1870, Oct. 12. — At 9:30 A.M. the General died quietly, fourteen days after he had been attacked. His physicians were quoted in the newspapers as saying that the immediate cause of his death was "mental and physical fatigue, inducing venous congestion of the brain, which, however, never proceeded so far as apoplexy or paralysis, but gradually caused cerebral exhaustion and death." No autopsy was performed.
It is not possible, of course, to come to any certain conclusion regarding the nature of General Lee's illness and the cause of his death. There are, however, certain points in the history that are very suggestive.
p525 First, the illness described at the end of March, 1863, of severe sore throat resulting in rheumatic inflammation of the sac enclosing the heart and accompanied by pain in the chest, back and arms occurring in paroxysms, may have been an acute pericarditis secondary to the throat infection.
In the absence of any definite statement with regard to pericardial friction sounds, the possibility of the so‑called rheumatism affecting the arm, shoulder and back may not have been rheumatism but may have been angina pectoris.
Second, the probability that the General suffered from angina pectoris is indicated by the history in 1869 in which it is stated that exercise produced pain and difficulty in breathing. It is likely that there was some myocardial insufficiency at this time also.
Third, the fact that in 1870 he speaks of his symptoms as stricture in his chest and says that if he goes beyond a very slow gait the pain is always there strongly indicates the existence of angina pectoris. The fact that he felt the pain occasionally even when he was quiet would not nullify this idea. The statement that the pain along the breast bone always returned on making any exertion is almost pathognomonic of angina pectoris.
Fourth, the statement that in 1870 there may have been some adhesions of the parts though not of the pericardium may really mean that the doctors were puzzled as to why he should have pain there without signs of pericardial involvement. Of course angina pectoris would explain.
Fifth, if there was pain in both shoulders and in the back there may have been some real arthritis in the shoulder joints and in the joints of the spine in addition to the angina pectoris.
Sixth, the account of the terminal illness in 1870 suggests either an atherosclerotic cerebral process or a uraemic process secondary to cardiorenal changes. The possibility of a terminal pneumonia must, of course, be kept in mind though nothing is said of fever.
The General seems to have been a man of florid complexion. It was before the days of blood-pressure determinations and it is quite possible that he had a hypertension associated with arteriosclerosis.
Summing up then I think it is certain that the General had angina pectoris, that he probably had an atherosclerotic process that contributed to the terminal event, and that in all probability he had some arthritis, and possibly a chronic adhesive pericarditis secondary to a throat infection.
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Robert E. Lee
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