Stalwart as he was, the general was often ill. A doctor studies his record and notes shortcomings in Eighteenth-Century medical care.
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August 1955
13 years ago By admin
Volume6Issue5
If one looks closely at Gilbert Stuart’s well-known portrait of George Washington, one observes an artificial bulging of the cheeks, as if they had been stuffed with cotton.
It has been reported that Stuart actually did use cotton to fill out the sunken cheeks of the illustrious sitter of this portrait, who at the time was wearing a set of ill-fitting dentures. In 1796), when the picture was painted, Washington was the proud possessor of two sets of these awkward and noisy contraptions, made of ivory. One of them had been manufactured by Paul Revere. Up to the Nineteenth Century dentistry in the modern sense was unknown. When something was wrong with a tooth, it was pulled out. So, at the age of 22, Washington had a toothache which was relieved by having the tooth pulled. This same radical treatment was used for every aching tooth over the years, and by the age of 57 he had hardly any teeth left and had to wear false teeth. Six years later his last surviving tooth was pulled.
In the portrait the head of Washington is covered with a white wig concealing the sparse remains of his own hair. It is reported that this hair had been reddish in his youth, turning, as he said, an early gray in the service of his country. The face of the President is covered with a rosy glaze in the picture. His real complexion was described by his contemporaries as sallow, a color that was even visible through the tan which the sun and wind had burned on his lace.
The painter also carefully retouched the pockmarks that deeply pitted Washington’s features. These blemishes Washington had acquired at the age of nineteen during an ill-fated journey to Barbados Island. He was at that time accompanying his brother and guardian, Lawrence, who was suffering from active tuberculosis of the lungs and was vainly looking for salvation in the balmy climate of the West Indies.
In his diary, Washington notes that he was “strongly attacked” by smallpox and was bedfast for three weeks. When he arose from his sickbed, he bore the marks of the disease and carried them to his grave.
In most portraits, the Father of His Country is shown as having a chest bulging with well deserved pride. The chest must have been tailor-made. Under the well-padded coat, Washington’s chest was Hat and somewhat hollow in the center, probably from early rickets. And the shoulders were not as broad as they appeared from the outside.
Colonel Tobias Lear, his devoted secretary and faithful friend, immediately after the death of the general, took his bodily measurements for posterity. He recorded Washington’s shoulders as one foot nine inches across, which is average for a man of the unusual height of Washington. He measured six feet three and a half inches tall. If Washington was that tall at the age of 67, he must have been at least one inch taller at the prime of life.
Like Lincoln, with whom he had many physical characteristics in common, Washington was in his youth a champion wrestler and rail-splitter. It is a curious phenomenon that the two greatest Presidents of the United States were also physical giants. Even by present standards Washington and Lincoln would be considered as unusually tall men. They were more outstanding for their size/e in their own time, when the average man was considerably smaller.
In spite of great physical strength and endurance, Washington was subjected to a host of diseases in his lifetime. He suffered from at least ten attacks of serious illness which on several occasions brought him to the brink of death. The question is whether Washington had more than his share of sickness in a period of history when a number of diseases were taken for granted, diseases which modern science has virtually conquered and which we have almost forgotten.
In Washington’s world a great percentage of babies died from nutritional deficiencies and diarrhea. If they survived they were exposed to the prevalent epidemics of which the most contagious ones were most apt to be acquired in early childhood. A number of such diseases confer upon their victims, if they recover, a lasting, even lifelong immunity. Therefore they occur rarely in later life, and so were called children’s diseases. Among them were measles, scarlet fever, whooping cough and diphtheria. Before the introduction of vaccination, even smallpox was considered a children’s disease in many countries.
If a person in the Eighteenth Century survived the trial period of infancy and childhood, he had to run the gauntlet of a legion of other diseases waiting for him on his life’s path. He was forever threatened by the White Plague, tuberculosis, which was the number one killer of the time. Then there was always malaria lurking in the swamps, ever present the various strains of dysentery easily transmitted by uncooked food and drink, and the enteric fevers—typhoid and paratyphoid, harbored in human carriers and transmitted by food, drinking water and the ubiquitous flies. Ever threatening were the pneumonias of different types.
Uncontrolled by antiseptics were the septic bacterias, the staphylococci and streptococci, which had a field day feasting in every wound. Like other disease germs, these shock troops of death can also enter the body through microscopic channels through the apparently unbroken skin and mucous lining.
Doctors of Washington’s time were incapable of giving a scientific explanation of most disease phenomena. The medical concepts of the time were based upon a hodgepodge of ancient beliefs, timehonored traditions, and the doctrines formulated over the centuries by the accepted authorities of medicine.
Unknown was the science of bacteriology. The causes of most diseases were absolutely obscure, as were the pathways of their transmission. A contamination of the air by a miasma was blamed for the spread of the majority of diseases. The miasmas were thought to emanate from putrescent matter and from swamps, and to float in the air. Some diseases were believed to be transmitted by polluted water, a theory which came close to the truth in the case of typhoid.
No specific remedies against most infections were known, except for quinine which had been found effective against the rigors of malaria, as had mercury against the sores of syphilis.
In his last play, Le Malade Imaginaire , Molière wrote the lines, “Nearly all men die of their remedies and not of their illnesses.” The medical therapy of Washington’s time had changed very little in the hundred years since Molière. It still used the same murderous arsenal consisting mainly of bloodletting, purgatives, emetics, enemas and blistering.
In order to understand some of the theories and methods of pre-scientific medicine as it was still practiced in Washington’s time, we have to realize that the first concepts and practices of the healing art originated in magic and religion in ancient times. Beneath the surface the doctors took over from the medicine men some of their rituals, and rationalized them as therapeutic measures. The most dramatic of these was the ceremony of bloodletting which had been performed by savage tribes since prehistoric times. The object of this rite was either to let the bad demons escape with the flowing blood, or to appease the spirits and gods by the sacrifice of blood.
Superstitions and traditions die hard, especially when they take the disguise of reason. Medicine justified the practice of bleeding by adopting the popular belief that blood was the carrier of the impurities and poisons of disease, and that by the removal of “bad” blood, the formation of new healthy blood would be engendered.
At the time of Washington the average amount removed in one bloodletting was one pint. The more serious the illness, the more blood was taken. It was then unknown that the mean blood volume of a person measures not more than seven per cent of the body weight, which meant about fourteen pints for a man of Washington’s weight at the age of 67. It was believed that some glandular secretion in the body could replace the amount of drained blood within a few hours, instead of the weeks that are actually required.
Since the dawn of history people have used laxatives and emetics, in the majority of cases doing more harm than good by dehydrating and weakening the patient. Laxatives have killed thousands of victims suffering from appendicitis by distending an inflamed and brittle appendix. Enemas were somewhat less dangerous if used with discrimination, but repeated colonic flushings as practiced by the doctors of the Seventeenth and Eighteenth Centuries weakened and exhausted the patient and seriously strained his tired heart.
Another practice often used by colonial physicians was the raising of blisters on the skin. This was based on the belief that an inflammatory process could be “drawn” from the inside to the outside by counterirritation. As it was usually done with caustic concoctions, it often produced severe chemical burns and inflicted unnecessary pain on the sufferer.
Altogether, if we consider the primitive state of preventive and therapeutic medicine in Washington’s time, it is small wonder that few persons reached old age. In the case of Washington, we know that his grandfather died at 37, his father at 49, probably from infectious diseases; on his maternal side we only know that his mother reached the age of 82.
From his mother, her first-born son George inherited not only his physical features but also his unusually strong constitution and powers of endurance. However, if we consider his medical history, we marvel that he ever reached the age of 67, when he succumbed to a streptococcic throat infection and to the medical mistreatment he received.
We do not know anything about the childhood diseases of Washington. From the diaries and letters of Washington and from the reports of his doctors and friends, we have an exact knowledge of the illnesses which attacked him after his sixteenth year. In his seventeenth year Washington was graduated from William and Mary College in Virginia as a public surveyor, a profession which he practiced for several years in Fairfax County. At that time great stretches of Virginia were dotted with swamps infested with malaria-carrying mosquitoes. Camping outdoors as a surveyor, Washington was promptly bitten by these malaria-carrying mosquitoes and suffered his first attack of malaria, called “ague.” During his later life Washington had repeated bouts of this intermittent fever.
We have already mentioned the severe case of smallpox which he contracted at nineteen during his sojourn at Barbados. This calamitous trip not only failed to cure the consumption of his brother, who died a few months later, but it brought George into close contact with the virulent tuberculosis bacilli as he nursed his brother, and they promptly invaded his body. Washington had barely returned to Mount Vernon, still weak from the smallpox, when the tubercular infection broke through the exhausted defenses of his system and manifested itself in the form of acute pleurisy. He recovered slowly and was in poor health many long months.
After two years the process must have been arrested, as Washington felt strong enough to enter military service. In October, 1753, he received a commission ;is major in the Virginia militia and was immediately ordered on a fruitless mission to the French commander of the Ohio Territory. During the next year he led a military expedition against the French at Fort Duquesne and was badly defeated. He had hardly returned when he was stricken with a severe attack of malaria.
In 1755 the English general, Edward Braddock, arrived in Virginia with several battalions of English troops. Braddock asked Washington to join his expedition against the French and Indians. The campaign had not progressed far when Washington fell ill with a febrile disease, apparently of the influenza type. He describes the experience in his diary in these words:
On the day before the battle of Monongahela Washington rose from his sickbed, still weak and barely able to sit on his horse. The battle itself, as every schoolboy knows, was a complete disaster. Braddock was killed, his troops were routed, and Washington managed to extricate the remainder of the detachment after two horses had been killed under him and his uniform pierced by four balls. He returned to Mount Vernon and wrote to one of his half brothers: “I am not able were I ever so willing, to meet you in town for I assure you that it is with some difficulty and much fatigue that I visit my plantations in the Neck; so much has a sickness of five weeks duration reduced me.” Two years later Washington contracted a severe type of dysentery accompanied with high lever and deep prostration which lasted for several months. Recovery was so slow and tedious that Washington became depressed and worried about his condition.
In the meantime the English government had sent a new general, John Forbes, with considerable reinforcements for a new campaign against the French and Indians in the Ohio Basin. The tonic of excitement invigorated Washington enough to accompany the English general as the commander of the advance guard. Washington had the great satisfaction that this, the third attempt to defeat the French in which he had participated, was successful. Fort Duquesne was taken and renamed Fort Pitt, later Pittsburgh.
After this campaign Washington resigned his commission, returned, and in January, 1759, married the widow, Martha Custis. Apparently marriage had a beneficial influence on Washington’s health. No sickness is reported in his diaries until 1761 when he had another attack which he believed to be malaria, though it may have been typhoid fever. He was bedfast for several weeks with pain and great prostration. Barely recovered, he had a relapse of fever which made him once more despondent and fearful that he was very near his “last gasp.”
There is no mention of any disabling sickness for the next six years, then he suffered another attack of dysentery. This was followed by the longest period of freedom from illness that Washington ever enjoyed, and which included the long years of the Revolutionary War.
If one scans the diaries of Washington, one is astonished by his gloomy outlook each time he was stricken by serious illness, and his readiness to anticipate a fatal outcome. Washington’s apprehensions were well founded. Of his nine brothers, half brothers and sisters, two died in infancy, the other seven between the ages of thirteen and 64. George survived them all, as well as his two adopted children. How could he expect to outlive all his close relatives with the exception of his wile, Martha?
Sickness affects different people in different ways. Long periods of disease accompanied by disability, pain and danger, such as Washington had to endure, exert a profound influence in molding a character. They are times of trial which soften the weak and temper the strong. Long periods of physical disability gave Washington the time to find himself and his ideal. Self-control and patience are masks which are acquired by long and painful practice in suppressing the natural outbursts of emotion and impatience. The sickbed is the best school in which to learn patience.
It can be assumed that other qualities which the mature Washington exhibited, his courage and unyielding determination, were also conditioned by his medical history. A man who has repeatedly faced death when attacked by unknown diseases, encounters with a feeling of relief enemies whom he can see and understand. And Washington’s singleness of purpose may have derived its force from the store of energy dammed up by the frustrations of sickness.
We have no record that Washington was ever incapacitated all during the Revolutionary War. Even at Valley Forge there was not a day when Washington was not at his post. The continuous strain of his responsibility and the consciousness of his mission kept on stimulating his adrenal glands, raising his normal powers of endurance, resistance and immunity. Destiny kept alive and well the only man of his time who could lead the American Revolution to victory.
Washington remained free of any disabling disease until 1786. Then, following the conclusion of the war and his election to the Presidency, came a letdown and he fell ill once more with “ague and fever.” He was treated by Dr. James Craik, who had been his physician for the preceding 32 years and had become his close personal friend.
In 1786 Dr. Craik for the first time employed “the bark” on Washington for malaria with excellent results. “The bark” meant the bark of the Chinchona tree which had been used for 140 years against malaria in South America and southern Europe. It was given in the form of a powder, decoction or extract, and was one of the first specific remedies employed for any disease.
In the first year of his Presidency there developed what the doctors called “a malignant carbuncle” on Washington’s left hip, probably of staphylococcic origin. For several weeks he was desperately sick and septic. He was cared for by Dr. Samuel Bard, a wellknown New York physician, who watched over the patient for many days and nights.
Finally Dr. Bard summoned all his courage, incised the carbuncle and drained the pus, with immediate improvement. Washington was confined to the house for nearly six weeks. When he was able to go out, his coach had to be reconstructed to enable him to lie at full length.
In 1789 Washington went on an official visit to New England. In the outskirts of Boston he was delayed a considerable time in rain and stormy weather because the city and state authorities were unable to settle a dispute as to the etiquette of receiving the Chief of State, for which there was no precedent. As a result, Washington developed a bad cold with some inflammation of the eyes. Following this visit, an epidemic: of respiratory infections spread through the city, and the die-hard Loyalists of Boston promptly named it “The Washington Influenza.”
As the result of colds and the large doses of quinine taken for his malaria, Washington’s hearing noticeably deteriorated during the last decade of his life. The deafness made it difficult for him to carry on conversations at public affairs, and increased his native diffidence. Therefore he acquired a reputation of being cold and aloof in society.
Like every person with normal vision, after reaching middle age Washington had to wear glasses for reading. In those days, the wearing of glasses was just as unfashionable as has been the wearing of hearing aids up to quite recently. People were ashamed to wear glasses, considering them a humiliating disfigurement like a clubfoot or hunchback. Washington used his reading glasses only in the privacy of his family and among intimate friends.
In 1790 the Federal Government was removed from New York to Philadelphia. In the spring of the same year Washington was taken with an attack of pneumonia followed by a relapse which almost proved fatal. He wrote: “I have already within less than a year had two severe attacks, the last worse than the first. A third probably will put me to sleep with my fathers.”
There is no doubt that the responsibility and the nervous strain connected with the Presidency were a great drain on the physical strength and stamina of Washington, as on all other Presidents since. Sixty-five years old, sick, and tired of public service, he declined to be nominated for a third term and retired to the privacy of Mount Vernon in the spring of 1797. He was allowed only two and a half years of well-deserved rest at his beloved Mount Vernon. In 1798 his old nemesis, malaria, recurred and responded only tardily to “the bark.”
On the day of December 12, 1799, as was his custom, Washington was riding about his farm from 10 A.M. until 3 P.M. The weather on this day was bad; rain, hail and snow falling alternately, driven by an icy wind. Washington was a stickler for punctuality in all his activities, including his meal hours. On this December day in 1799, Washington was late for dinner. Served promptly at three o’clock, the meal was on the table when he entered the house. Colonel Lear, his faithful friend and secretary, observed that the neck of the general appeared wet and that snow was sticking to his hair, but Washington refused to change his clothes and sat down to the dinner.
The next day he complained of a cold and sore throat and did not go out as usual in the morning. In spite of his cold he went outside in the afternoon to mark some trees which he wanted cut down. In the evening a severe hoarseness developed, but he made light of it. Upon retiring, Colonel Lear suggested that the general take something for his cold, but Washington answered, “No, you know I never take anything for a cold; let it go as it came.”
On the following day at three o’clock in the morning Washington told Martha that he was very unwell, that he had the ague. He could scarcely speak and breathed with difficulty. Martha begged him to let her awaken the servants and fetch him a home remedy. But Washington sternly refused to let her get up for fear she, too, would catch a cold.
At daybreak a servant came and lighted the fire. Soon Colonel Lear arrived and found the general voiceless, hardly able to utter an audible sound. A loathsome mixture of molasses, vinegar and butter was offered to Washington but he could not swallow a drop. As he tried harder to get it down, he started to cough convulsively, and almost suffocated. Rawlins, the overseer of the farm, was sent for with Washington’s request to bleed him.
The overseer had acquired his surgical acumen in the practice of veterinary medicine. He took a pint of blood from Washington, but there was no relief. Colonel Lear next applied “sal volatile,” the menthol-vapor rub of the time, to the throat of the sick man, rubbing it gently with his hand, upon which the patient complained that his throat was very sore. A piece of flannel saturated with the same evil-smelling salve was wound around his neck, and the feet bathed in warm water, all to no avail.
About eight o’clock Washington got up for two hours, but obtained no relief from the changed position. Dr. Craik arrived shortly after nine o’clock. He applied a blister of Spanish flies (derived from dried and powdered blister beetles) to the throat, took some more blood, and prescribed a gargle of vinegar and sage tea. He also ordered vinegar and hot water for steam inhalation. In attempting to use the gargle, the patient almost choked and regurgitated the liquid. At eleven o’clock the bleeding was repeated but the difficulty in swallowing and breathing did not improve. In the meantime Dr. Gustave Richard Brown, of Port Tobacco, and Dr. EIisha Cullen Dick, of Alexandria, had been summoned as consultants.
Both consultants arrived around three o’clock and sat down at the bedside of the patient. The clinical diagnostic methods of percussion and auscultation, tapping the chest and listening to the breath sounds, were not yet practiced at that time. Neither is there any record that the interior of the throat of Washington was ever inspected by the attending physicians. A diagnosis was arrived at by watching the patient and observing his external symptoms. The three doctors attending Washington saw their patient struggle for breath, each inspiration producing a shrill, harsh sound as the air was painfully sucked in through the obstructed air passage. His skin was blue and the nostrils dilated and contracted with the effort of breathing. In addition to this, the patient had great difficulty in swallowing.
The first diagnosis thought of was quinsy, which means “peritonsillar abscess.” Later on the diagnosis was changed to “cyanche trachealis,” an indefinite medical term of the time for a severe sore throat involving the voice box, in which the inflammatory swelling of the vocal chords encroaches upon the breathing space. Dr. Brown suggested using the standard treatment for this condition; namely, to resort to a more copious bleeding. The young American doctor, Dick, objected. He argued, “He needs all his strength—bleeding will diminish it.” He was overruled by his two senior colleagues who were supported by the good soldier, Washington. A whole quart of blood was taken this time and it was observed that the blood came “slow and thick,” the effect of dehydration.
To add insult to injury, the laxative, calomel, and the emetic, tartar, were administered, weakening the patient still further. About half past four Washington gave instructions about his will, and about five o’clock he tried to sit up, but was too weak to remain upright for more than half an hour. In the course of the afternoon he appeared in great distress and pain, and frequently changed his position in bed, struggling for breath.
As a last resort Dr. Dick suggested the use of a new, revolutionary method, the only one available which could have saved the patient from slow suffocation caused by the obstruction of the larynx, “tracheotomy”—the surgical cutting of an opening into the windpipe below the point of obstruction. In a communication several years later Dr. Dick reasoned, “I proposed to perforate the trachea as means of prolonging life and of affording time for the removal of the obstruction to respiration in the larynx which manifestly threatened immediate dissolution.”
The older colleagues refused to take a chance on their illustrious patient by using such an unproved and daring procedure, which, in the annals of medicine, had been employed in only a few instances up to this time with success. The urgent entreaties of Dr. Dick were in vain. Instead of it, the polypragmatic senior physicians continued their futile measures by applying blisters and cataplasms of wheat bran to the legs and feet of the dying patient. The process of gradual suffocation progressed inexorably until about ten minutes before the general expired, when the breathing became easier. The exhausted heart stopped beating between ten and eleven o’clock on the evening of December 14, 1799.
From the first, Washington as usual had been exceedingly pessimistic about his illness. He had made up his mind that he was going to die and did what he could to dissuade his doctors from making special efforts for him, and begged them to let him die in peace.
“I find I am going,” he whispered to Colonel Lear. “My breath cannot last long. I believed from the first that the disorder would prove fatal.” And a little later he repeated the same conviction to Dr. Craik: “Doctor, I die hard, but I am not afraid to go.” And later when Dr. Brown came into the room: “I feel myself going; I thank you for your attention but I pray you to take no trouble for me. Let me go quietly. I cannot last long.”
The exact diagnosis of George Washington’s last sickness is still a matter of dispute among medical historians. The most convincing study was made by Dr. W. A. Wells of Washington, D. C., in 1927. Up to that time it was believed that Washington had died from diphtheria, corresponding to the diagnosis of “croup,” which Dr. Dick had suggested in retrospect. A final diagnosis cannot be made with certainty, as no clinical description of the appearance of the inflammatory process has been given, and bacteriological confirmation of a diagnosis was unknown. In spite of this lack of evidence, Dr. Wells concluded from all the known data that Washington died from a streptococcic laryngitis, an inflammatory swelling of the larynx and the vocal chords caused by a strain of virulent streptococci. We are unable to estimate how much the treatment with depleting venesections and dehydrating cathartics and emetics contributed to the fatal outcome.