When Confederate Army general Robert E. Lee died five years after the Civil War ended, the cause of his death had doctors stumped. He had been in poor health, but his specific illness was a mystery; there weren't many clues beyond symptoms Lee had described in letters. “The troops are not encamped near me and I have felt so unwell since my return as not to be able to go anywhere,” he wrote to his wife in 1863.

This was before electrocardiograms and x-rays existed. There were no obvious physical findings to support a formal diagnosis, either. Lee’s doctors made some educated guesses based on his gripes and treated him with everything but the kitchen sink: hot mustard plasters and footbaths, doses of turpentine or ammonia, and enemas, all of which were standard medical treatments in the Civil War era. Without a robust medical history to guide them, the doctors diagnosed stroke, rheumatism, and pneumonia in the months leading up to Lee's death.

Now, research from East Carolina University sheds light on the age-old question of what actually caused Lee's demise, thanks to the discovery in a photograph of a crease running diagonally across Lee’s right earlobe. According to the case study, recently published in the American Journal of Cardiology, the crease is a physical sign that Lee likely died from heart disease.

Richard Reinhart, an emeritus professor of medicine at East Carolina University and author of the paper, says earlobe creases can help detect heart disease. Some previous reports have pointed to heart disease as the cause of Lee’s death based on written evidence, but “until now there hadn’t been an actual physical finding supporting this diagnosis,” Reinhart tells Mental Floss. “His earlobe crease is the only piece of objective physical evidence that helps back it up.”

Virginia Historical Society

The possible connection between earlobe creases and heart disease was first made in 1973, and there have since been more than 120 studies investigating the link. Scientists aren’t sure why creases appear in the earlobes of some heart disease patients, but researchers have suggested that a heart condition may affect the blood vessels and elasticity of the earlobe in a way that forms a crease over time.

Reinhart, a history buff who has a particular interest in the life of Lee, saw a close-up photo of the general at the Virginia Historical Society one day and noticed the wrinkle on his ear. Aware of the possible link between earlobe creases and heart disease, he began poring through Lee’s personal letters and attending physicians’ notes, as well as previous reports of Lee’s illness, to see if his symptoms jibed with a failing heart.

It turned out the symptoms correlated well: Lee initially had an episode of chest pain in 1863, which progressively worsened when he exerted himself and eventually took on characteristics that would be recognized today as heart disease. And in the months before his death in 1870, he began to have chest pain even at rest, which suggests a heart attack was imminent.

“The constellation of symptoms, I believe, are readily explained by heart failure due to progressive coronary artery disease,” Reinhart says.

In an age where advanced medical diagnostic tools weren’t yet in play, a physical feature like an earlobe crease would have been a useful visual cue had doctors known it might signal heart trouble. But even if they had known, could they have done anything to help Lee? One option—a nitroglycerin-based substance called amyl nitrite, which dilates the coronary artery for better blood flow to the heart—had been documented in the British medical journal Lancet in 1867 but wasn’t used much clinically. Salicylate, the precursor to aspirin, which today's physicians recommend for preventing heart attacks, had been around since before the Civil War. But the idea of using it as an anti-platelet drug wouldn't occur for decades.

“Understanding heart disease back then was in its relative infancy, and I don’t think there’s anything that would have turned Lee’s condition around,” Reinhart says. “Even today, I believe the outcome from his final illness—end-stage heart failure—may not have been much better, given that the mortality rates for it are still significant.”