A Modern Medical Analysis of the Last Illness and Death of George Washington
George Washington's Terminal Illness
White McKenzie Wallenborn, M.D.
29 March 1999
On December 12th, 1799, George Washington in his 67th year of life, rode out around his farms on horseback from ten a.m. until about three p.m. The weather that day according to General Washington was snowing in the morning and about three inches deep. Wind at NE and mercury at 30 (30 degrees Fahrenheit). Continued snowing until about one o'clock, and at about four o'clock it became perfectly clear. Wind at same place-not hard. Mercury 28 (28 degrees Fahrenheit) at night. Colonel Tobias Lear, George Washington's secretary, stated that the weather that day was bad, rain, hail, and snow falling alternately with a cold wind. When George Washington returned from his ride, the General's neck appeared wet, snow was hanging from his hair, and he came to dinner without changing his dress (clothes wet?).
The next day, Friday December 13th, 1799, the General did not go out as usual for he had taken cold and complained of a severe sore throat. He did go out in the afternoon to mark some trees which had to be cut down. He now had hoarseness which increased in the evening. He spent the evening reading the papers, and when he met anything interesting, he read it as loud as his hoarseness would permit.
On the next day, Saturday the 14th, at three o'clock in the morning, he told Mrs. Washington that he was very unwell and that he had an "ague" (paroxysmal chills). It was observed that he could hardly speak and that he breathed with difficulty. At daybreak on the 14th, Colonel Tobias Lear came in and found the General breathing with difficulty and hardly able to utter a word intelligently. A mixture of molasses, vinegar, and butter was given but he (GW) could not swallow a drop and when attempted, he appeared to be distressed, convulsive, and almost suffocated. Later he tried to use a gargle of vinegar and sage tea but in attempting to gargle, he almost suffocated and when the gargle came back from the throat some phlegm followed. At eleven a.m., his swallowing had not improved. After the last bleeding it was noted that the blood came "slow and thick" but there was no fainting (his physicians had ordered that he be bled a number of times in the course of his illness and an incredible amount, about eighty-two ounces or about five pints or units, of blood were removed from him). At half past four o'clock, Washington gave directions about his will and at about five he again tried sitting up but remained so only half an hour. In the course of the afternoon, he appeared in great pain and distress from difficulty in breathing, and frequently changed his position in bed. At about eight o'clock it was noted that his condition remained unchanged and did so until about ten minutes before his decease (death) when breathing became easier. He died between ten and eleven p.m. December 14th, 1799.
His primary symptoms in the order of their occurrence were -- severe sore throat, hoarseness, cough, chills, difficulty with breathing, difficulty with swallowing, expectoration (spitting-? drooling), fever, loss of voice, and suffocation.
From the observations of Colonel Lear, Dr. James Craik, Dr. Elisha Cullen Dick, an Dr. Gustavus Richard Brown, and the clinical course of his illness, I think that it is very reasonable and possible to make a determination of the disease process that was the cause of George Washington's death. He had acute epiglottitis (supraglottitis) which is a severe, rapidly progressing infection of the epiglottis and surrounding tissues that may be quickly fatal because of sudden respiratory (airway) obstruction by the inflamed structures. The epiglottis is located at the base of the tongue and is the most superior part of the larynx (voice box). It is at the very entrance to the airway which goes through the larynx to the trachea and lungs. Swelling of this structure is painful and tends to rapidly obstruct the airway and also the entrance to the hypopharynx (area just above the esophagus) and the esophagus (gullet). With acute epiglottitis, George Washington would have had great difficulty breathing, talking, and swallowing and these he certainly had.
The onset of epiglottitis is usually acute and fulminating. Sore throat, hoarseness, dysphagia (difficulty swallowing), and respiratory distress accompanied by drooling, shortness of breath, rapid pulse, and inspiratory stridor (harsh high pitched respiratory noise heard while the patient is inhaling [breathing in]) develop in rapid order. Death from this dysorder is caused by obstruction of the patient's airway and is very painful and frightening.
The other possible dysorders suggested by some as being the disease process that caused George Washington's death were acute diphtheria (laryngeal diphtheria), quinsy, acute laryngitis, and Ludwig's angina. However none of these diagnoses quite fit the description of Washington's terminal illness but on the other hand acute epiglottitis does explain all of his symptoms and his demise. His illness is a classic "textbook" case of acute epiglottitis.
Laryngeal diphtheria is an unlikely diagnosis for several reasons. General Washington was reported to have survived a case of "black canker" as a child. This would have been diphtheria and would have given him lifetime immunity against future attacks of diphtheria more than likely. There were no other reported cases of diphtheria in his household or farm population so the likelihood that he would have picked up a case of diphtheria was remote. Diphtheria in an adult is a very rare occurrence. Although this diagnosis is a possibility because it can produce laryngeal obstruction and respiratory distress, it just doesn't fit the picture.
Quinsy is the term used to describe a peritonsillar abscess. Quinsy produces a sore throat but it is almost always unilateral (on only one side of the throat) and produces symptoms referable to that side only, e.g. soreness, swelling of the neck on that side, and another symptom: trismus (a lockjaw-like symptom where the patient cannot open their mouth). This diagnosis also does not fit the disease process from which General Washington died.
Acute laryngitis in an adult is not usually a life threatening dysorder.
Ludwig's Angina is an infection in the floor of the mouth in front of or lateral to the tongue. It usually results from a dental or periodontal infection. George Washington had no teeth, ergo not a likely diagnosis.
It would be improper for today's medical practitioners to be critical of the physicians of George Washington's day if they were delivering the standard of care that other physicians of that era were giving to their patients. It would appear that Dr. James Craik, Dr. Elisha Cullen Dick, and Dr. Gustavus Richard Brown were well trained as physicians, were honest and caring, and gave the kind of medical care that their peers would have given. Today we know that many of their methods were wrong and we would do things differently. If Drs. Craik and Brown would have encouraged Dr. Dick to perforate Washington's trachea (tracheostomy), it might have allowed him to survive the acute illness and live on for sometime afterwards. However this procedure was new and controversial so they were not totally wrong to oppose it. Technically it might not have worked anyway . . . but who knows? Today we find the removal of about eighty-two ounces of blood (about five pints or units of blood) from a sick patient in less than sixteen hours to be incredible. However this was the method of treatment being taught in those days. It was the treatment of choice for many diseases and the complications of using this method were not comprehended by the physicians of that day. I certainly have a great deal of compassion for George Washington's physicians who were attempting to save his life by using the methods that they thought best for him. I am also filled with sadness that such a remarkable man and leader should have such a painful and frightening end to his life.
White McKenzie Wallenborn, M.D.
Clinical Professor (Ret.)
Department of Otolaryngology-Head & Neck Surgery
University of Virginia School of Medicine
November 5, 1997
References
In the study of George Washington's terminal illness, a number of textbooks of Otolaryngology were consulted. William Abbot and Dorothy Twohig, Editor in Chief of The Papers of George Washington at the University of Virginia, provided a number of valuable articles written about George Washington's death and his overall medical history. By combining the textbook articles, the journal articles, and my own clinical experiences, I was able to reach the conclusions noted above. The journals used are listed below:
- Barker, Creighton. "A Case Report," The Yale Journal of Biology and Medicine, 9 (1936), 185-87.
- Blanton, Wyndham B. "Washington's Medical Knowledge and Its Sources," Annals of Medical History, 4 (1932), 52-61.
- Brickell, John. "Observations on the Medical Treatment of General Washington in His Illness," Transactions of the College of Physicians, 25 (1903), 90-93.
- Courtney, John F. "George Washington's Final Illness," Resident and Staff Physician, 15 (1969), 84-.
- Knox, J. H. Mason, Jr. "The Medical History of George Washington, His Physicians, Friends and Advisers," Bullentin of the Institute of the History of Medicine, 1 (1933), 174-91.
- Lewis, Fielding 0. "Washington's Last Illness," Annals of Medical History, 4 (1932), 245-48.
- Nydegger, James A. "The Last Illness of George Washington," Medical Record, 92 (1917), 1128.
- Wells, Walter A. "Last Illness and Death of Washington," Virginia Medical Monthly, 53 (1926-27), 629-42.
- Willius, F. A., and Keys, T. E. "The Medical History of George Washington (1732-1799)," Proceedings of the Staff Meetings of the Mayo Clinic, 17 (1942), 92-96, 107-112, 116-121.