The health and controversial death of George Washington.
Assume that medical practice in George Washington's day had paralleled that of the 21st century. Washington's physician would have had his medical records on file, complete with his personal and family history, physical examination findings, and test results. Such a record would have shown that although Washington's mother had survived until the then-exceptional age of 82, his inheritance with respect to health was otherwise essentially poor. Members of the Washington family were generally short-lived. George's great-grandfather John Washington died at age 46, his grandfather Lawrence at 38, and his father Augustine at 49.
An impressive array of illnesses
Washington's strong and stalwart appearance notwithstanding, his personal medical history included an impressive array of illnesses, some of them serious. Once he was grown, the earliest entry in his chart would probably have been made in November 1751, when at age 19 he was "strongly attacked with the Small Pox" during his stay on the island of Barbados in the West Indies. 
Soon after Washington returned to America in March 1752, he suffered an attack of pleurisy. Aware of young Washington's exposure to tuberculosis, with which his brother Lawrence had been afflicted, his physician might have suspected that George had also contracted this malady and had eventually overcome it over a period of years. Auscultation and x-ray might have detected the presence of healed scar tissue or an active lesion.
The recurrent chills and fever that had plagued Washington at intervals of many years and that mercifully receded with doses of "the bark" would have been identified as malaria.
During the summer of 1755, Washington had been wracked with pain and fever of another sort that yielded neither to determination nor to doctoring until British General Edward Braddock ordered him to take Dr. James's Powders. This bout with "bloody flux" left Washington's strength much impaired. In the summer of 1757, he experienced a dysentery that persisted for months and forced him to seek a "change of air." Washington obtained no relief from this weakening illness until March 1758.
In 1761, Washington contracted a severe cold and intermittent fever that "stirred up old maladies," evidently pulmonary.  This attack prompted him to seek relief in the mineral baths at Berkeley Springs in what is now West Virginia. Except for a digestive disturbance of 5 days' duration in early 1768, Washington was singularly free of all but minor illness for most of the remainder of his life. (Washington was wearing false teeth by 1789, although he had not lost his last tooth until 1795).
Overcoming his diathesis
Even with his poor health inheritance and history, Washington by his own efforts was able to alter his body's diathesis and thus lessen his susceptibility to respiratory infection, to build up a measure of resistance to disease and exposure, and to strengthen his recuperative powers. Otherwise, he would not have been able to endure the rigorous demands of the War of Independence with an almost perfect health record or survived the other strains of his military and political life. His personal habits were good. He arose at dawn and usually retired at 9p.m. He did not smoke and he was not given to excessive eating or drinking, although he did partake of the wine usually served at his dinner table and often after dinner. Throughout his life, he was an ardent disciple of exercise in the open, and always after an illness he returned to the saddle as soon as possible.
This self-imposed regimen of outdoor exercise, careful diet, and regular rest had been in a sense his best medicine. It was both preventive and therapeutic. Although he had already suffered many illnesses and had considered himself at age 54 to have reached his declining years, at age 65 he took up a vigorous schedule at Mount Vernon upon leaving the presidency. At the time he was last stricken, the prospective plans on his desk were those of an active man.
When Dr. James Craik examined Washington on the morning of Dec. 14, 1799, he pronounced a diagnosis of "inflammatory quinsy." Craik's consultants, Dr. Gustavus Richard Brown and Dr. Elisha Cullen Dick, agreed with Craik that the seat of the infection lay in the larynx. However, Dick suggested that his elder colleague's diagnosis was too vague, and he proposed that Washington's condition should be specified as "tracheitis stridula suffocatis--or laryngen." Craik and Brown preferred the original diagnosis.
Doubtless, the two older men, graduates of the School of Medicine at Edinburgh, were familiar with the writings of Dr. William Cullen. At that time, Edinburgh was the internationally acknowledged center of medicine, as London was of surgery. Cullen, a professor of medicine at Edinburgh, was regarded as being without peer in his field, and his textbook was "the bible" for physicians of the 1790s.  Despite Dick's misgivings, the diagnosis and handling of Washington's illness were made in accordance with Cullen's description of symptoms and his recommendations for treatment. One of the prescribed treatments that was administered-phlebotomy--would become the center of a searing controversy when Washington died later that day.
Shortly after Washington's death, the three physicians came under some criticism, which worsened as the years passed. Some of the more vitriolic critics published analyses and opinions of the case that were abusive--particularly in their condemnation of the bloodletting. Furious attacks were directed against not only the individual physicians, but the entire profession. Wrote one lay critic, Paul Leicester Ford, "There can be scarcely a doubt that the treatment of his last illness by the doctors was little short of murder." 
It should be remembered that Washington's attending physicians did not consider themselves infallible. Aside from their own conservatism and a respect for the orthodox medical practices of the day, they also respected Washington's wishes and beliefs. The General had been a firm advocate of bloodletting, and it had been an approved treatment for him, his wife, his servants, and his slaves. The same was true of blistering and purging.
Nor did the two older men ignore their junior colleague, either at Washington's bedside or thereafter. Although Dick's opinion had not prevailed, he had made a lasting impression on his seniors with his "clear reasoning and evident knowledge of the causes of certain symptoms."  In retrospect, his argument that the General had suffered a "violent inflammation of the membranes of the throat" rather than an attack of quinsy is convincing. In fact, Craik for a moment had been inclined to concur with Dick's recommendation to perform a tracheotomy. Moreover, a few weeks after Washington's death, Brown wrote of Dick in a letter to Craik: "I have often thought that if we had acted according to his suggestion when he said, 'He needs all his strength--bleeding will diminish it,' and taken no more blood from him, our good friend might have been alive now. But we were governed by the best light we had; we thought we were right, and so we are justified." 
Here indeed is a forthright statement, a regretful doubt, and a measure of self-reproach. But medicine then was still in the pre-scientific era. The 18th-century rationale for phlebotomy was the idea that blood contaminated by morbid matter must be evacuated and that it would be replaced within a few hours by healthy blood. The more serious the illness, the more the impurities in the blood, and therefore the more copious the bleeding should be. But physicians of the time knew very little about blood volume, and they did not even suspect that the process of blood replacement takes weeks instead of hours.
Although Dick had opposed the bleeding of Washington, venisection had been the uniform remedy that he had used with uniform success to treat croup in 40 children and several adults during that same winter of 1799. If some members of the profession occasionally questioned the virtues of bleeding, many more decades would pass before it ceased to be the accepted therapeutic procedure for almost every form of illness.
Two hundred years of scrutiny
Even as succeeding generations came and went, there remained some interest in dissecting both the diagnosis and treatment of Washington. In 1860, Dr. James Jackson offered his own "enlightened diagnosis."  He wrote that Washington's final illness had been acute laryngitis, in which inflammation had extended beyond the mucous membrane of the larynx to the surrounding tissues. Yet even during that Civil War era, bloodletting was still the specific cure, the great remedy, almost precisely as it had been in Washington's day. Only the justification had changed. In explaining the new 19th-century rationale for venisection, Jackson wrote that because a loss of blood causes surface vessels to contract, it was hoped that those in the affected area would also contract, thereby reducing the local swelling and making it possible for serous fluid in the tissues to be absorbed more readily. 
In 1931, Dr. Wyndham Bulling Blanton offered a partial defense of Washington's physicians when he concluded, "The vigorous therapy resorted to by his physicians may have hastened Washington's death, but it could in no way have caused it." 
An interesting paper on this subject was presented in 1942 by Drs. F.A. Willius and T.E. Keys.  Reviewing the bitter controversy, wide speculation, and arguments set forth by other physicians, they conducted a careful analysis and arrived at their own diagnosis: "The true nature of Washington's terminal disease was not laryngitis, for laryngitis is not fatal; the course of the illness was too short of quinsy to have been fatal; and the possibility of diphtheria was untenable because of probable immunity by previous infection, and because of advanced age--diphtheria seldom is found in a person of 67." Willius and Keys concluded, "The modern American physician in all probability would sign the death certificate in the following manner: septic sore throat, probably of streptococcic origin, associated with acute edema of the larynx."
Dr. Rudolph Marx, writing in 1955, was not charitable to Washington's physicians.  He emphasized that Washington had been weakened not only by the bloodletting, but by other procedures as well (blistering, emetics, and laxatives) and that his heart had been severely taxed. Marx believed that Washington had succumbed to a streptococcal throat infection and to the medical mistreatment he received. However, because of the lack of a clinical description of the appearance of the inflammatory process and bacteriologic confirmation, Marx argued that a definitive diagnosis cannot be made retrospectively.
It appears likely then that the controversies surrounding the circumstances of Washington's death will continue. Yet it seems unreasonable to condemn the practices of an era out of time and out of context. Having been examined through the microscopic lens of hindsight and history, Craik, Brown, and Dick should not be denounced for their backwardness, but be judged fairly according to the standards of their day. What would be gross malpractice in 2001 was state-of-the-art in 1799.
From Charles B. Witt, Jr., MD, FAGS, cardiothoracic surgeon, Los Angeles.
Reprint requests: Charles B. Witt, Jr., MD, 321 Larchmont Blvd., Suite 905, Los Angeles, CA 90004, Phone: (213) 384-6000; fax: (323)464-7141.
(1.) Freeman DS. George Washington. Vol. 1. New York: Scribner, 1948:251-2.
(2.) Freeman DS. George Washington. Vol. 3. New York: Scribner, 1948:62-3.
(3.) Cullen WF. First Lines of the Practice of Physick. Reviewed by: Garrison FH. An Introduction to the History of Medicine. 2nd ed. Philadelphia: W.B. Saunders, 1917:358.
(4.) Ford PL. The True George Washington. Philadelphia: J.B. Lippincott, 1896:58.
(5.) Letter of Gustavus Richard Brown to James Craik, Jan. 2, 1800. In: Lossing BJ. Pictorial Field Book of the Revolution. Vol. 2. New York: Harper and Bros, nd.
(6.) Jackson J. Memoir on the last sickness of General Washington and its treatment by the attending physicians. In: Everett E. The Life of George Washington. New York: Sheldon and Co., 1860:278.
(7.) Jackson J. Memoir on the last sickness of General Washington and its treatment by the attending physicians. In: Everett E. The Life of George Washington. New York: Sheldon and Co., 1860:284.
(8.) Blanton WB. Medicine in Virginia in the Eighteenth Century. Richmond, Va.: Garrett and Massie, 1931:310-1.
(9.) Willius FA, Keys TE. The medical history of George Washington (1732-99). Proceedings of the Staff Meetings of the Mayo Clinic 1942; 17:14.
(10.) Marx R. A medical profile of George Washington. American Heritage 1955;6:43-7, 106-7.
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|Author:||Witt Jr., Charles B.|
|Publication:||Ear, Nose and Throat Journal|
|Article Type:||Brief Article|
|Date:||Feb 1, 2001|
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