Lessons from Washington’s Treatment: We Must Question Current Practices

Rodney P. Lusk, MD, AAO-HNS/F President In last month’s Bulletin, I depicted the circumstances of George Washington’s death through eyewitness accounts. The diagnosis and treatments have not lacked controversy. Historian Peter R. Henriques indicated that Washington’s diagnosis was most consistent with acute epiglottitis (supraglottitis)—rapid onset of symptoms, high fever, an extremely sore throat, drooling, great difficulty swallowing and speaking with progressive airway obstruction (especially when leaning backwards) relieved only by sitting upright, persistent restlessness or agitation, and finally, apparent improvement before death. George Washington slowly and painfully suffocated to death for many hours. In their accounts, Drs. James Craik and Elisha Cullen Dick said, “General Washington was attacked with an inflammatory affection of the upper part of the windpipe, called in technical language, cynanche trachealis.” Their accounts reveal symptoms most compatible with acute epiglottitis. In 1997, White McKenzie Wallenborn, MD, a retired University of Virginia otolaryngology professor, offered an article about Washington’s probable diagnosis and the effects of his therapy titled “George Washington’s Terminal Illness: A Modern Medical Analysis of the Last Illness and Death of George Washington.” He concurred that the most likely diagnosis was acute epiglottitis. Other possible diagnoses were acute diphtheria, quinsy, acute laryngitis, and Ludwig’s angina. However, laryngeal diphtheria is unlikely as he was reported to have survived “black canker” as a child and been immune to diphtheria. Quinsy, or peritonsillar abscess, is almost always unilateral and the symptoms would have included trismus and unilateral lymphadenopathy, which was not noted. Acute laryngitis in an adult is not life threatening. Ludwig’s angina is a floor of the mouth infection and usually the result of dental or periodontal infection. By the time of his death, Washington had lost all of his teeth and wore poorly fitting dentures; therefore such infection is unlikely to have caused his death. By all accounts, Drs. Craik, Dick, and Gustavus Brown were well-trained, honest, and caring physicians. They delivered the standard of care for that era. However, Washington would have been treated differently today. In our practices now, we work to deliver not only quality care, but also appropriate, individual care based on evidence and judgment. Unfortunately, these fellows had little else but their own learning and experience to guide them. While Dr. Dick recommended a tracheal perforation (tracheostomy) and was willing to accept the consequences of a poor outcome, his recommendation was firmly overruled by Drs. Craik and Brown as it was a controversial, new procedure. But, the most controversial of the treatments was the venesection, or bloodletting. It was common practice and George Washington himself believed in its efficacy. Although not a physician, Washington’s overseer, George Rawlins, was experienced with the technique and performed it many times on the general’s slaves. He performed the first venesection at Washington’s request. Four subsequent bleedings by Drs. Craik and Dick resulted in the depletion of 82 ounces of blood, more than half of his blood volume, in about 13 hours. James Brickell, MD, about eight weeks later, wrote an article objecting to this practice and the judgment of the physicians, concluding that the aggressive bloodletting attributed to Washington’s rapid demise. But the article was not published until 100 years later. We should not applaud his clinical prowess, however. His solution was “to have attacked the disease as near its seat as possible [by opening] the vein under the tongue; the tonsils might have been sacrificed; the scarificator and cup might have been applied on or near the thyroid cartilage.” Washington would likely not have survived his therapy. Although it is not widely discussed, he was also given several agents, calomel and emetic tartar, causing copious diarrhea that no doubt also contributed to his hypovolemia. His calmness at the time of his demise might well have been secondary to the resulting hypovolemia. As we now know, a tracheotomy might have prolonged Washington’s life. Dr. Dick is reported to have pleaded with Drs. Craik and Brown not to perform additional bleedings, but do a tracheotomy instead. The procedure was well accepted in Europe since 1718 for treatment of respiratory distress associated with diphtheria, but not well known in the United States. Understandably, the two senior physicians were not willing to perform any treatment never before attempted in this country on their famous patient. Looking back on Washington’s care, we can now point to many critical mistakes. Lest we be too critical, with the advent of increasing knowledge of human genetics and treating diseases on the molecular level, our current therapies will be viewed as equally barbaric. Learning of this account renewed my understanding that we must always be willing to question current practices and conventional wisdom. When you come to Washington, DC, for the annual meeting, come early or stay late and enjoy all the opportunities for learning. You may even take the 14-mile trip to Mount Vernon and see the room where the father of our country died.