Weary of the hyperbole surrounding the Obama inauguration, I picked up Joseph Ellis' biography His Excellency: George Washington to help put things in perspective. This excellent biography included many fascinating details about the life of our first president, but for me, a physician, none were more interesting than the account of the president’s death in 1799, at the age of 67. Like many health care professionals, I have made something of a minor hobby of guessing the medical ailments of historic figures and fictional characters. Besides, I wanted to write a short essay for President’s Day, and since it is pretty clear what killed Lincoln, the death of our “other” greatest president seemed an obvious topic.
First the facts. One morning in mid-December 1799, Washington went out, as it was his daily habit, on horseback from his home to inspect his Mount Vernon property. That particular day the weather was very cold and there was an ice storm. It is said that Washington spent five hours out in freezing rain, then returned home and dined with guests in his wet clothes because he did not want to keep them waiting. The next day he complained of a sore throat and was hoarse, but otherwise appeared well. The following night he awakened Martha to tell her that he felt a severe pain in his throat, and was having trouble breathing.
The next day his personal physician, Dr. James Craik, was summoned. Craik diagnosed the condition as life threatening, and hastily assembled a team of doctors for aggressive treatment. They bled him of five pints of blood, burned his neck, and gave him calomel, a mercury compound used as a purgative but which probably did little more than induce mercury poisoning. Finally, after several days of this torture, Washington displayed the judgment that made him a great president and told them to stop. According to Ellis: “Eventually Washington ordered his doctors to cease their barbarisms and let him go in peace. ‘Doctor,’ he muttered, ‘I die hard, but I am not afraid to go” (p.269). He expired a few hours later.
Ellis’s explanation of the death fascinated me. “Modern medical experts,” he said, “have concluded that Washington most probably suffered from a virulent bacterial infection of the epiglottis.” The epiglottis is a cartilage flap in the throat that slams shut during swallowing, protecting the airway from food particles. Infection of the epiglottis, or epiglottitis, leads to extreme swelling which can block the airway and cause suffocation.
Now for a little analysis. I have read a few accounts of Washington’s death and every single one of them begins with story of him riding in the sleet. Before I debate the issue of the epiglotitis, this part of the story needs to be dispensed with. Throat infections are caused by bacteria or viruses, and cold weather has little to do with it. Especially irksome is the assumption so many authors have made that not taking his wet clothes off after the ride was relevant. Wet clothes don’t produce bacteria, or attract it, or necessarily increase its virulence. Washington had to get the infection from someone else, but nowhere in the history is there an indication of a sick contact, or even a local epidemic. Hypothetically, Martha’s goodbye kiss as she sent her husband on his way after breakfast posed a greater risk to our Founding Father. Unfortunately, Martha’s health, as well as the state of health of everyone else in Mount Vernon at that time, is lost to history.
This association of cold weather and moisture with infections is an old wives’ tale, but like all old wives’ tales there is a grain of truth in it. It is possibly true that prolonged hypothermia or the stress of exposure to the elements could weaken the immune system enough to make a person vulnerable to infection. This however is just a guess. Experts have long debated why some infections such as strep throat and influenza are more prevalent in the winter months, but so far there have been only theories. It is not thought that cold alone is a significant cause, since there are many infections that are more common in the spring and summer.
The point is that the cold weather may have been a minor contributing factor, but as far as pointing to a cause of death, it is a red herring.
Ellis’s assertion that the immediate cause of death was epiglotitis genuinely surprised me. Looking at various sources, I found that at least two recent publications have argued that epiglotittis is the culprit, so Ellis is not alone. Earlier theories have suggested quinsy, also known as peritonsillar abscess, and Ludwig’s angina, which is when a strep throat infection tunnels its way under the surface of the throat all the way to the chest and infects the mediastimum, or heart cavity.
The reason I find epiglottitis surprising is that modern medicine knows epiglottitis as an infection almost exclusively of young children. The bacterium that usually causes this disease is known as Haemophylis influenzae type B, or Hib for short. Hib infection incurs lifelong immunity, which means once you have had it, you are not likely to ever get it again. Hib was, before there was a vaccine for it, an extremely common infection. Most people who got Hib infection didn’t get epiglottis, but they were infected by Hib and so became immune to it. This, then, explains why epiglottittis is a disease of children — in the general population, usually only young kids have not been exposed.
For a 67 year-old man to have this type of infection strikes me as very extraordinary. On the other hand, there may be something about disease prevalences in colonial America I do not know about. Washington grew up in rural Virginia, and may simply have had too isolated a childhood to have been exposed. (It also raises the interesting proposition that a sick baby in Mount Vernon could have brought down the man who so bedeviled the great British Army.) But this seems unlikely. It is also true that epiglottitis can rarely result from bacteria other than Hib, but before we give Washington up to a rare infection, we ought to consider more likely possibilities.
I prefer the argument that Washington died of quinsy. (I also like the word quinsy, which comes from the Greek word kynanchÄ, meaning “to strangle a dog.” Back in the old days, doctors used creative words to describe ordinary illnesses. Quinsy is much more elegant than PTA, or peritonsillar abscess, the term used today.) Quinsy begins with a typical strep infection. Washington could easily have contracted strep throat — it is common in the winter, and there is no lifelong immunity; so Washington, as a senior citizen, would have been vulnerable. The infection then spreads and enlarges under the tonsil, forming a glob of pus under the surface — an abscess. As the abscess enlarges, swelling gradually spreads downward toward the larynx, where the airway and the throat meet. Swelling can cause airway obstruction, and the infection can leech into the bloodstream, producing a dangerous condition called sepsis. Sepsis is often fatal, even today.
But whether it was quinsy or epiglotitis or Ludwig’s angina, all authorities agree that Washington’s medical treatment was major aggravating factor. Some go as far as to say the doctors killed Washington more than the disease did. Washington’s doctors bled him of at least 3.75 liters of blood. Since total blood volume in an adult is about 5 liters, the doctors were very close to murdering territory. That the president was able to survive such a massive bloodletting without immediately dying suggests to me that the throat infection was not as life threatening as Dr. Craik thought. Anyway, I don’t entirely trust Craik’s dire prognosis — there is little reason to trust the medical judgment of a man who thought bleeding a patient of 80% of his blood volume was a good idea.
Craik, however, shouldn’t take all the blame — Washington himself seems to have approved of the bloodlettings. According to one account, when one of the doctors, a Mr. Rawlins, hesitated to let the blood flow, Washington said, "Don't be afraid. The orifice is not large enough. More, more." Barbaric medical treatments aside, they don’t make presidents as tough as Washington any more.
Washington had used bloodlettings for years to treat illnesses in his own slaves, so I guess he also deserves some credit for his willingness to accept the same health care he gave own slaves. But the great irony is that, since Washington freed his slaves in his will, he probably benefitted his slaves more when he bled himself than when he bled them.
And in one final ironic twist, Martha appears to have been against bleeding. Ever a faithful student of the science of the Enlightenment, George ignored his wife’s advice and followed the informed opinion of some of the best-trained physicians in the western hemisphere. If he had simply done what most husbands in history would have done and obeyed his wife, he might not have died.
But either way, he’d still be dead today. Which goes to show that common sense may be the best medicine, but there are limits to what even common sense can do. Let’s just all be thankful that the doctors didn’t get hold of our Founding Father until after he left office.
Here’s to you, Mr. President. And happy President’s Day to all.