George Washington (1732-1799)

George Washington was one of the founders and the first President of the United States of America. Born in Bridges Creek, Westmoreland, Virginia in 1732 into the nobility of Virginian landowners, he had the opportunity to enjoy the preparation of a good cultural background (Figs. 1, 2). He was destined to a military career and held various offices of responsibility which he always conducted throughout, with or without good fortune, eventually being made a General. Once he left the army, he took part in other war activities, albeit dedicating his interests also to agriculture, in which he achieved excellent merits. In 1774, he took part in the movement towards independence of the American States, through military actions, coordinated with political affairs which led to his fame as a great leader (Figs. 3, 4). Following the difficult victory against the English at Monmouth (1778), the endeavours of the General for independence became more and more important. In 1783, having made peace with the English, he left the command in the hands of Congress. In 1786, he was elected President of the constitutional Convention of Philadelphia which drew up the text of the American Constitution. As far as concerns the work involved in the Convention and the text of the Constitution, Washington had a very strong influence, conferring great power upon the President’s figure, which, at the time, represented a definite guarantee of strength for the Confederation (Fig. 5). Elected the first President of the Union, he came to power on 30th April, 1789 and governed with a great sense of responsibility. He was re-elected in 1792 for a further four years. During his second term of office, strong reactions were manifested by the radicals on account of Washington’s pro-English attitude which led to a severe crisis at executive level, with some ministers standing down. In 1796, at the end of his term of office he decided not to stand again for re-election, publishing a farewell message to the American nation, which has remained famous, and he retired to his farmland in Mount Vernon, Virginia where he died on 14th December 1799, following an acute disease lasting only 21 hours.

Fig. 1.

The Washington family in a print taken from a painting by Alense Chappel (from: Storia dei popoli e delle civiltà. Turin: UTET 1974;vol.XVI)

Fig. 2.

George Washington on the veranda of his home in Virginia, together with the Marquis Lafayette (from: Storia dei popoli e delle civiltà. Turin: UTET; 1974;vol.XVI.)

Fig. 3.

The Americans guided by Washington cross the Delaware during the night of 25 December 1776 (painting by Emanuel Leutze, New York, Metropolitan Museum of Art).

Fig. 4.

Washington inspects the Eastern forces at Fort Cumberland (painting attributed to James Peale. New York, Metropolitan Museum of Art).

Fig. 5.

Constitution of the United States in the text proclaimed at the constitutional Convention in Philadelphia chaired by G. Washington.

Diary of the disease leading to the death of G. Washington

On 13th December 1799, after having inspected his farm on horseback in the rain, he complained of a slight sore throat, considered to be due to the beginning of a cold. The next night, between 2 and 3 a.m. he woke up and had difficulty in breathing and pain upon swallowing. He did not go back to bed, also because the symptoms were becoming worse. In the morning, at breakfast time, he summoned his farmer and old friend Tobias Lear ordering him to proceed with bleeding him, a treatment which was very popular at that time for any kind of disease, which was practised not only by physicians but also by ordinary people. Approximately 250 ml of blood were collected. At 10 o’clock that morning, Dr James Craik and Dr Gustavus Brown arrived, both of whom physicians to the patient, as well as very good friends. Examining Washington, they found an inflamed throat but on account of the symptoms: pain in the throat, difficulty in swallowing and pain when talking, a diagnosis of inflammatory quinsy was made, i.e., stenosis of the upper airways which can lead to suffocation. The two doctors ordered a more copious bleeding and another 250 ml of blood were removed. As time passed and no improvement was observed, they decided to ask Dr Elisha Cullen Dick to come. This young physician from Alexandria, whom they very much admired, got his degree in Medicine at the University of Pensylvania. Whilst waiting for Dr Dick, since there was still no sign of improvement, Craik and Brown bled the patient for the third time.

At 3 in the afternoon Dr Dick arrived and after having examined the illustrious patient, he consulted with the two senior colleagues, suggesting that a tracheotomy be carried out. On account of the obstruction in the airways this was the only feasible treatment, but apparently this procedure was little known in America. Nonetheless, Dick, convinced that this was the only way that might save the life of G. Washington, declared that he was prepared to take full responsibility for eventual consequences. Craik was, initially, in favour of proceeding, but when Brown pointed out that the patient could die during the operation, he changed his mind. The three doctors then agreed that a fourth bleeding should be performed. A total of 32 ounces of blood were removed – almost 1 litre – which added to the previous bleedings came to a total loss of blood of almost 2 litres. The patient, obviously showed signs of weakness, but preferred to remain in a sitting position on account of difficulty in breathing. Meanwhile, his state of restlessness increased. At 8 o’clock in the evening, vescicants were placed on his legs and a fibre collar put around his throat. At 10 o’clock, breathing became lighter and the situation seemed to be improving, but at 11.30 the patient died. His doctors, devoid of resources, were beside his bed.

The post-mortem

Five days later, Craik and Brown published a report in the Alexandria Times describing the sequence of events leading to the death of the first President of the United States. Referring to cynanche trachealis or squinantia, which in latin medical jargon, from which it derives, simply meant inflammation of the trachea: nothing could have been more generic, but what could one expect at a time when the specialization of otorhinolaryngology had not yet been born. Violent attacks were launched against them: some considered that the patient had been suffering from croup (William Cobett) and that had Washington been placed in a cold bath for 4 hours, followed by brandy and goose fat rubbed onto his neck and chest, he would have been cured; others believed that instead of copious bleeding, he would have benefited more from withdrawal of a small amount of blood from the tonsil area or from a vein under his tongue (John Brickell). Dr Dick insisted on the validity of tracheotomy, as he had previously proposed.

Certainly tracheotomy was indicated but, as already pointed out, the decision to carry out this procedure was hampered by the risks involved, namely the poor general conditions of the patient and lack of experience of American doctors in the use of this technique. In Europe, this procedure had been known for thousands of years, but until the 16^th Century had rarely been carried out in man on account of the high death rate involved. Following the anatomical studies of Andrea Vesalio, others, including Ambroise Parè, Fabricio d’Acquapendente and Giulio Casserio became convinced as well as converted and, indeed, prognosis began to improve. At the end of the 16th Century, the first epidemics of diphtheria began which greatly increased the need for tracheotomy. In the 19th Century, this operation was widely practised, also because a surgical instrument developed by Pierre Fidèle Bretonneau greatly improved prognosis. Later, Armand Trousseau altered the trend that had until then been followed, advising that the operation be carried out as soon as possible. But George Washington became ill in 1799, at a time when reserve and fear still reigned also in Europe.

What was the real cause of death of G. Washington? An attack of acute stenosing laryngitis? The interpretation of H.H.E. Scheidemandel, who published an article on this topic in 1976 (which gave us the idea to prepare this note), was that this was a case of acute epiglottitis. That there had been a lesion at epiglottis level appears very likely from the description of the symptoms reported in the official documents. We certainly have to use a little imagination, as always when interpreting history at a distance, and historians are perfectly at ease when they have to create hypotheses and then the elements to support them. But in the present case, it would certainly appear to have been a lesion at epiglottic level. Inflammation? Abscess? Foreign body? If Manuel Garcia had discovered the use of the laryngeal mirror before G. Washington’s illness, the diagnosis would have been much more precise and rapid, and treatment would have probably been successful. Instead, exploration of the larynx began more than 50 years later, in 1854. Until then, in order to indicate what was happening beyond the isthmus of the fauci, the terms squinanzia or cinanchia were used and as far as concerns therapy, triaca was still fashionable, invented, according to historians, by Andromaco, Nero’s physician or, according to others, by Mitridate (triaca was the association of a large quantity of medicines, which differed according to the time and place where they were produced: in the 16^th Century it was sought after in all the world and Venice made a flourishing market from it). Was triaca already known in America at the time of George Washington’s illness? Reports make no mention of it, but even if it had been available, it would not have been possible to give it to the patient because he would have been unable to swallow it. Thus it would have been useless!