Hektoen International

A Journal of Medical Humanities

General Robert E. Lee’s myocardial infarction: Did illness impact the Battle of Gettysburg?

Lloyd Klein
San Francisco, California, United States

A bearded man with short light-colored hair leaning on a sword and wearing a dress coat and a belt with two long tassels
Robert E. Lee in March 1864[?]. Photo by Julian Vannerson. Library of Congress.

Ascribing the loss of the Battle of Gettysburg to an illness of General Robert E. Lee became common among historians thirty years ago. The legend of his apparently poor judgment in ordering Pickett’s Charge, when appraised in view of his other outstanding military results, has baffled historians, thus appearing to require an explanation.1-3 The juxtaposition of two unrelated vignettes makes an intriguing “what-if” story and conforms with a mythological view of Lee as a wily fox who rarely made tactical errors. However, with the perspective of a contemporary cardiologist who has studied the history of the US Civil War in detail, it is highly unlikely that his strategic decision-making at Gettysburg was impaired by a medical illness.

Several detailed and erudite professional medical descriptions of General Lee’s physical condition both during and after the war strongly suggest that he suffered from atherosclerotic disease. It is very likely that he incurred a myocardial infarction in March 1863. He probably died of a stroke in 1870 following several months of rest angina pectoris.4 Some have inferred from his letters and professional observations that he had congestive heart failure and atrial fibrillation in the weeks before the stroke. A rarely seen photograph of him in June 1869 shows a rather ill-looking older gentleman who appears pale and uncomfortable, not his usual handsome and impeccable appearance of just a few years earlier.5

Did General Lee have a myocardial infarction before the Gettysburg campaign? Of course, it is impossible to time travel and perform a physical examination, ECG, cardiac enzymes, and echocardiogram. We are dependent on the careful observations of very competent physicians of the time, who were also entirely unaware of the presenting signs and symptoms of ischemic heart disease. Thus, we have to intuit what they may have observed based on their diagnosis at that time. Although they were probably familiar with Heberden’s classic description of angina, the clinical diagnosis was rarely made until the 1930s.

General Lee was described by those who knew him in 1863 as robust, graceful, strong, and reserved. The most noticeable change since the start of the war was that he had become gray.6 On March 6 he wrote his wife that he was feeling worn out; several weeks later this had become a “violent cold.”7 It is not unusual for patients to ascribe symptoms of an acute myocardial infarction to a “cold” or “flu.” Lee’s symptoms were first noted in a letter to his wife dated March 27, 1863: “The troops are not encamped near me & I have felt so unwell since my return [from Petersburg] as not to be able to go anywhere. I have been suffering from a heavy cold which I hope is passing away.”8 Additional documentation noted, “He had not been sleeping well and he contracted a serious throat infection which settled into what seemed to be pericarditis. His arm, chest and his back were attacked with sharp paroxysms of pain that suggest even the possibility of angina.”9 Lee wrote, “It came on in paroxysms, was quite sharp,” and affected his ability to ride a horse. His health in the spring of 1863 has been noted to include the onset of angina.10 Lee suffered from what his doctors diagnosed as pericarditis in April 1863,11 which had a sudden onset and presented as paroxysmal pain in his chest, back, and arms.12 It is widely thought that this was his first sign of cardiac illness.

On April 30 he had a recurrence of chest pain and conducted business that day in his tent.13 Despite his symptoms, Lee defeated General Hooker and the Army of the Potomac on April 30-May 6, 1863 at Chancellorsville in what is generally considered his greatest victory. Moreover, on April 9, 1863, Lee proposed to the Secretary of War that the army cross into Maryland.14 In May and June, he planned his campaign into Maryland and Pennsylvania, meeting with Jefferson Davis and opposing a proposal to stay on the defensive while General James Longstreet’s corps was detached and sent west. He sent orders to General DH Hill to send specific brigades to him to be used in the coming battle. During his move northward and during the Gettysburg campaign, Lee makes no mention in his correspondence of any symptoms related to illness. Reports of a subordinate (General Pender) from this time describe a vigorous man in complete charge, riding over thirty miles in a single twenty-four-hour period.15 He was on horseback during the march into Pennsylvania, and during the battle itself, he rarely got to bed before 1:00 a.m. and arose well before dawn.16

The Battle of Gettysburg was a “meeting engagement” in the sense that neither side planned to have a battle. The battle occurred because of a chance meeting at that crossroads town. Scholarly renderings of the battle17,18 show that Lee did not want to have a general engagement until all of his troops were in position. Because of the entry of various army elements and the geography of the land, one became inevitable. The famous “fishhook” configuration of the Union army was entirely based on the geography of the high ground south of the town. Lee’s army was outnumbered overall, but on the first day he had more troops on the field, especially in critical positions. On the second day, because of a misplaced army corps, the Confederate army came very close to breaking the Union lines. Lee at all times made the decisions regarding the disposition of his troops, riding back and forth to discuss his plans with all three corps commanders. Although Longstreet was critical of Lee’s offensive-mindedness on the second day, he never questioned Lee’s cognition or mental acuity.19

On the second evening, General Lee was faced with a serious dilemma. Having failed to penetrate the Union army’s flanks, he had to decide what to do the next day. He could not advance by his left flank by way of the town, as that would prolong his supply line in front of the Union position. Longstreet famously suggested advancing around his right flank beyond Little Round Top; but in fact there were no roads in that direction, and unbeknownst to him the Union VI Corps was stationed on the Baltimore Pike just behind the Round Tops. He could have entrenched and waited for an attack, but it was Lee who was on offense and we know that Meade had a number of reasons not to attack him. Lee could retreat; but then his campaign would have been criticized as a failure, especially given the fall of Vicksburg to Grant. In essence, Lee had no good options.17, 20

Lee chose to attack the Union center, believing that the reason that the flank attacks had failed was because of heavy concentration there. Reconnaissance had failed to demonstrate the strength of the Cemetery Ridge position because the flat area at the top was short, and the men and their equipment were placed on the other side of the ridge where they could not be seen. This decision in fact was the “textbook” correct answer based on tactics from the Napoleonic wars. However, the use of artillery had materially changed war since that time, a factor that Lee had not foreseen. This was not a poor judgment of the moment; he had made a very similar decision at Malvern Hill a year before that resulted in the Union army retreating. The fact is, General Meade had predicted this attack, telling General Hancock the night before: “If there is an attack tomorrow it will be in your front.”17

Severe cognitive dysfunction that impacts decision-making is not typical of acute myocardial infarction. It may occur in those who experience shock or cardiac arrest with cerebral hypoxia. A subtle judgment deficit in the absence of other mental or physical manifestations is unknown as a medical entity. Moreover, there was never clinical evidence of such a profound event nor of any subsequent cognitive dysfunction or judgment deficit. Indeed, Lee carried on his complicated military duties for another two years, with diminishing assistance from subordinates. The battles of the Overland Campaign demonstrated that Lee continued to have great management and strategic skills after Gettysburg. As Tucker concluded, “Lee offered no apologies for his failure at Gettysburg, and needed none.”21

Second-guessing the rationale for Pickett’s Charge is a favorite pastime of Civil War amateur and professional historians. Since Lee did not leave an explanation, oral or written, we can never know the rationale for his decision. But whatever military factors influenced his judgment, it is impossible to support by medical evidence any impact of the after-effects of a heart attack more than three months later.


  1. Reinhart RA. Robert E Lee’s medical history in context of heart disease, medical education and the practice of medicine in the Nineteenth Century. National Museum of Civil War Medicine. https://www.civilwarmed.org/surgeons-call/lee/
  2. Mainwaring RD, Tribble CG. The cardiac illness of General Robert E Lee. Surg Gynecol Obstet 1992 Mar;174(3):237-44.
  3. https://www.wearethemighty.com/mighty-history/robert-e-lee-may-have-lost-gettysburg-because-of-a-heart-attack/
  4. Douglas Southall Freeman, “Lee”. Collier, New York, 1991. Pages 565-566.
  5. Freeman op cit page 569.
  6. Glenn Tucker, “High Tide at Gettysburg”. Konecky & Konecky, Old Saybrook, CT, pages 49-54.
  7. Stephen W Sears, “Chancellorsville”. Mariner Books, Boston, 1996. Page 94.
  8. Clifford Dowdy, Ed., The Wartime Papers of R. E. Lee (New York: Bramhall House, 1961) 419.
  9. 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.
  10. Stephen W Sears, “Gettysburg”. Mariner Books, Boston, 2004. Page 1.
  11. Edwin B Coddington, “The Gettysburg Campaign. A Study in Command”. Charles Scribner Sons, New York, 1968. Page 628.
  12. Sears Chancellorsville op cit. Page 94.
  13. Sears Chancellorsville op cit Page 174
  14. Lee to James Seddon, 9 April 1863 in Dowdy, Wartime Papers, op cit. page 431.
  15. Coddington op cit Pages 105 & 628.
  16. Freeman op cit.
  17. Sears Gettysburg op cit
  18. Harry W Pfanz, “Gettysburg: The First Day”. The University of North Carolina Press. Chapel Hill 2001.
  19. Harry W Pfanz, “Gettysburg: The Second Day”. The University of North Carolina Press. Chapel Hill 1987.
  20. Coddington, op cit. Pages 394- 395.
  21. Tucker op cit.
  22. Coddington op cit. Page 390.

LLOYD W. KLEIN, MD, is Clinical Professor of Medicine, University of California, San Francisco. He is a nationally recognized cardiologist with expertise in coronary revascularization strategies. Dr. Klein is a pioneer in the objective assessment of quality assessment and appropriate use in coronary interventions. He has championed the measurement of risk-adjusted outcomes to evaluate interventional program and operator quality and participated in the development of numerous clinical and interventional practice guidelines. He is an amateur historian who has read extensively on the Civil War with a particular interest in political and military leadership and economic policies.

Highlighted in Frontispiece Volume 13, Issue 2 – Spring 2021

Winter 2021




Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.