The Terminal Illness
On September 28, 1870, Lee returned home after an evening meeting, but when he attempted to say the mealtime prayer, he could not utter any words. General Lee had sustained a stroke. Lee's condition was described by his friend Colonel William Preston Johnston.
There was a marked debility, a slightly impaired consciousness, and tendency to doze; but no paralysis of motion or sensation and no evidence of suffering or inflammation of the brain ... He took without objection the medicines and diet prescribed and was strong enough to turn in bed without aid and to sit up to take nourishment. He ... evidently understood whatever was said to him and answered questions briefly but intelligently. 
Drs. Madison and Barton were summoned immediately, and following a careful examination that revealed no paralysis, a normal heart rhythm and no morbid heart sounds, they diagnosed venous congestion of the brain. Over the ensuing two weeks, the two doctors were in constant attendance of their famous patient. Ironically, a severe storm hit the Shenandoah Valley, resulting in flooded rivers, washed out bridges, and nearly impossible difficulties with transportation. As a consequence, communications from this remote town were nonexistent, and news of General Lee's illness did not reach Richmond until October 4th.
The stroke that Lee sustained had unusual manifestations predominantly because there was no paralysis. It is also evident that his reception of speech was intact and that he was capable of short answers when he chose to do so. However, his wife and his physicians were frustrated by his mutism and inertia. A modern interpretation of this condition suggests the diagnosis of abulia, literally meaning absence of will. This clinical picture, although rare, can be caused by a discrete stroke in the area of the cingulate gyri.
The quality of medical treatment provided by Drs. Madison and Barton equalled the standard of care available during the mid-19th century. Much of the focus was on bowel and bladder function, and of the two dozen medications prescribed for Lee, more than 80% purportedly had desirous effects on these systems. Drs. Madison and Barton were to report their observations and medical treatment in the Richmond and Louisville Medical Journal. A typical entry follows.
September 29, 8 and ½ am-Passed a comfortable night. Pulse, 80 and soft. Respiration, 16. Temperature, normal; no unnatural heat about his head. Tongue, slightly furred. Consciousness, improved. Eyes, slightly suffused. Disposed to doze but easily aroused, and responds intelligently yes or no to questions. Evidently understands whatever is said to him. Takes nourishment readily. Deglutition, easy. When frequently asked if his head ached, he replied, No! His symptoms indicating sluggish capillary circulation in the brain, a blister was applied behind each ear and to the back of his neck, and he took Rx-Liq. ammoniae acetatis Spts. aeth. Nitrici Potass. chlorat. M.S. tablespoonful every 3 hours The evening found him with no material change of condition, or symptoms. Ordered a purgative enema, which acted slightly. Diet-Mutton broth, tea and coffee; the latter as cerebral stimulant, which He takes with relish. He raises himself, with little or no assistance, to the sitting posture to take nourishment. 
Many of the medications prescribed were probably homeopathic, either having no effect whatsoever or given in a small enough dose that the expected physiologic effect would not be observed. Some of the medications on the list are striking, such as the administration of turpentine (a paint thinner) and strychnine (a poison). It is also notable that General Lee was prescribed morphine, which, in large enough doses, can cause somnolence and respiratory depression. However, Lee remained reasonably alert until the last 24 hours of his life, suggesting that the morphine preparation likely had minimal active ingredient.
On October 11th, Lee's course took a dramatic turn, as documented by his physicians.
October 11-Evidently sinking; less observant; pulse 120; very feeble; respiration hurried. Still recognized whoever approached him. Refuses to take anything unless presented by his physicians. It soon became evident from his rapid and feeble pulse, deepening unconsciousness and accelerated breathing, that his case was hopeless. 
General Robert E. Lee died at 9:30 a.m. on October 12, 1870 at the age of 63. Drs. Madison and Barton summarized their care of the General in the following manner.
In reference to the proximate cause of his death we were of the opinion that it was due to passive congestion of the brain, not proceeding far enough to produce apoplexy or effusion. There was no positive evidence of acute softening, of cerebritis or of embolism. There was no paralysis of motion or sensation but marked debility from the first. His symptoms, in many respects, resembled concussion without its attendant syncope. The treatment was based upon the above diagnosis. 
South Med J. 2005;98(8):800-804. © 2005 Lippincott Williams & Wilkins
Cite this: The Lexington Physicians of General Robert E. Lee - Medscape - Aug 01, 2005.